this lecture should be about a bunch of review information to evaluate the neurologic system and neurologic function in your patient I want to take just a little bit to make sure that we're all on the same page um before we jump into talking about some of the different disorders because if you can't Define normal then it's very hard to understand abnormal the nervous system consists of two parts you have your central nervous system and you have your peripheral nervous system the central nervous system is made up of the brain and the spinal cord the peripheral nervous system is the cranial and spinal nerves and the autonomic and somatic nervous systems the nervous system functions to control motor sensory um autonomic cognitive and behavioral activities the nervous system helps put a little bit of control on everything that goes on in our body a neuron is the basic functional unit of the brain it's composed of dendrites a cell body and an axon and so if you look at the picture on this slide you can see that the dendrites receive electrochemical messages and the axons are going to carry those electrical impulses away from the cell body um the neuron is supported and nourished by what we call glial cells without functioning neurons messages can't get from point A to point B neurotransmitters communicate messages from one neuron to another or to a specific group of Target tissues neurotransmitters can potentiate or terminate or modulate a specific action or they can excite or inhibit target cells so they can start it they can stop it or they can adjust it is what that is saying they are manufactured and stored in our synaptic spaces neurotransmitters that you need to be familiar with are listed here on this slide if you think back to pharmacology you talked about many of these neurotransmitters as they relate to your sympathetic and parasympathetic nervous systems so the nervous system the neurotransmitters that you need to to review are acetylcholine serotonin dopamine nort epinephrine Gaba and endorphin many neurologic disorders are caused by imbalances in neurotransmitters for example Parkinson's disease is caused by decreased dopamine level so acetylcholine bonding is impaired in myasthenia gravis patients you need to go back and review just basic anatomy of the brain there's three major areas of the brain you have the cerebrum the brain stem and the cerebellum and so I've put pictures here just to remind you about where these parts are located because some of the disorders that we're going to talk about over the next several lectures are going to be specific to affecting one particular part of the brain so you need to understand where we're talking about the major bones and structures of the skull are highlighted here you need to go back and review location for the following bones frontal temporal parietal occipital and sphenoid cerebral circulation is affected if the brain doesn't store nutrients it requires a constant supply of oxygen in order to effectively provide circulation to prevent ischemia it's important to understand the different functions of the brain that are highlighted here as it relates to each lobe of the brain um so that when you care for a patient with an injury to a particular area of the brain you have a better understanding of how they might be affected the blood brain barrier makes the central nervous system inaccessible to many substances like drugs especially chemo medications and antibiotics that circulate in the plasma it serves as a protective mechanism that may be altered anytime that there's trauma cerebral edema or hypoxia structures that help protect the brain are the skull the meninges and the receiver cerebrospinal fluid the meninges um provide protection support and nourishment the cerebrospinal fluid um is important for immune and metabolic functions um if there is a blockage of cerebrospinal fluid it can lead to a condition called hydrocephaly in the patient remember that the spinal cord runs from the base of the brain all the way down to the end of the spine and so this here just shows you a cross section of a an area of the spinal cord so you can actually see where the cord runs down through the middle of that bony structure and then of course that right hand picture just shows you the spinal column remember your spinal column is broken up into several sections you have your cervical section which is up at the the top um kind of in the neck region you have your thoracic which is that middle chunk kind of the the chest the abdomen area um and then you have your lumbar um which will be the lower back you also have the sacrum and the coccyx that are part of that spinal column and of course those are at the very tip um down toward the buttocks remember that the peripheral nervous system um houses the cranial nerves the spinal nerves and the autonomic nervous system um the cranial nerves are going to come in 12 pairs there are three that are responsible for sensory function five that are responsible for motor function and then four that have a mixed feature you need to make sure that you review your cranial nerve functions and how to assess those um it is very important when we are talking about neurologic dysfunction in your patient for you to be able to properly assess those cranial nerves to get a better insight into what's going on in your patient you can remember your cranial nerves by the sentence old operators occasionally troubleshoot trick tricky abducted family veterans Galloping valiantly across history the o in old is for olfactory the O and operators is for optic the O and occasionally is for oculomotor the T in troubleshoot is for trochlear the T in tricky is for trigeminal the a in abducted is abducens the F in family is for facial the v in veterans is for vestibulocochlear the G in Galloping is for glossopharyngeal the V invaliantly is for Vegas the a in across is accessory and the H in history is for hypoglossial again it is very important for you to assess and and know what those cranial nerves do as far as function the spinal nerves each have a ventral root and a dorsal root the dorsal roots are sensory in nature they trans impulses from an area of the body known as the dermatome um sensory fibers sometimes are somatic so they carry information about pain temperature touch position um from the tendons joints and body surfaces sensory fibers can also be visceral so they carry information from those internal organs um ventral roots are motor in nature they transmit impulses from the spinal cord to the body and they also can be somatic or visceral the autonomic nervous system is designed to regulate the activities of internal organs so the heart the lungs the blood vessels the digestive organs and our glands it is designed to maintain as well as restore homeostasis the main center of the autonomic nervous system is the hypothalamus there are two divisions of the autonomic nervous system there's the sympathetic nervous system which produces that fight or flight response the main neurotransmitters there are norepinephrine you also have epinephrine and dopamine and then you also have the parasympathetic nervous system that's designed to control mostly visceral functions um that rest or digest effect in your patients and remember the main neurotransmitter with the parasympathetic system is acetylcholine this slide here just has two different diagrams or pictures on it for you to highlight the functions of the parasympathetic and the sympathetic nervous system remember that parasympathetic system um is going to be when the body is is trying to rest and digest um where that sympathetic system is going to be that stress response that fight or flight response and so you can look at these pictures and kind of see physiologically what happens in the body when each of those systems become stimulated within the nervous system you have motor pathways and sensory Pathways the motor pathways are the upper and lower motor neurons um these lesions manifest differently depending on where they are at the sensory pathways are going to convey heat cold pain position and vibration the thalamus integrates sensory impulses except for smell information is relayed from the thalamus to the parietal lobe for interpretation the main focus of this chapter really starts here and that is with your nursing assessment it is important for you to assess and evaluate what it is that you're seeing in your patient especially if your patient has some sort of neurologic injury or dysfunction um so you want to make sure you get a good health history you want to ask about pain is the pain that they're having acute or is it chronic look for seizure activity if they have had a seizure is it isolated is it associated with fever with drug or alcohol use is it caused from blood sugar um issues how long did it last how intense was it um seizures often will be related to one area of the brain and so you want to make sure that you are really documenting what it is that you're seeing because that may may help tell the provider a lot of information um are they having dizziness are they having any sort of abnormal sensation related to balance or movement are they experiencing vertigo um do they feel like the room is spinning in circles around them are they having any kind of visual disturbances visual disturbances can be acute or quick onset but it can also be a chronic change over a long time frame um are they having any nystigmas any sort of abnormal eye movements double vision blurry vision any of those changes are they experiencing weakness um weakness sometimes can be sudden sometimes it can be a temporary weakness other times it can be a permanent weakness and then other times it can be a very Progressive loss of ability to perform um due to weakness abnormal Sensations typically abnormal Sensations are going to be associated with pain or weakness when you're thinking about a neurologic injury what is their past health history what is their family history what is their social history these pieces of information are very critical and lead to Accurate Diagnostics and diagnosis for your patient [Music] as far as the neurologic assessment itself evaluate Consciousness and cognition this is their mental status their intellectual function their thought processes their emotional status their language abilities and how those things are impacting their lifestyle accurate thorough descriptions are needed in order to be able to make comparisons over time with this information evaluate this cranial nerves okay um evaluate their motor function look at their muscle size the tone the strength of those muscles how coordinated they are are they able to balance um think about doing a Romberg test remember Romberg test is a screening test for balance that can be done when the patient is sitting or standing the they will sit or stand with their feet together with their arms at their side and their eyes closed for 20 seconds a little swaying is normal but if they lose their balance if they are like falling over because of their swaying then that is abnormal and that is considered a positive Romberg Sun you want to look at the sensory system look at their tactile sensation can they feel okay um and if they feel are they interpreting what they are feeling adequately are they having superficial pain are they having temperature instability um are they feeling any sort of vibrations um evaluate reflexes deep tendon reflexes are very important to assess um reflexes can be reviewed in your book as far as techniques on how to manage those reflexes and we'll look at those a little bit more in depth over on the next slide deep tendon reflexes are graded on a scale of zero to four zero is no response one is diminished or hypoactive two is normal three is increased it may be interrupt interpreted as normal um and four is hyperactive or hyperreflexia you may see clonus the foot is dorsiflexed and maybe uh it may beat several times before coming to a rest with clonus um so let's flip on over to the next slide um and take a look at those reflexes [Music] in the first picture picture a on the top left you see the bicep reflex in order to elicit this you need to strike the bicep tendon over a slightly flexed elbow The Examiner will support the forearm the elbow with one arm while placing the thumb against the tendon and striking the thumb with the reflex Hammer normal response here is flexion at the elbow and contraction at the bicep muscle in that top middle picture picture B you see the tricep reflex this is kind of the opposite of that bicep reflex here the patient arm is flexed at the elbow and hanging freely at their side um The Examiner is going to support that arm identify that tricep tendon and strike it with a reflex Hammer normal response is contraction of the tricep and extension of the elbow picture C you see the patellar reflex with the patellar reflex you're going to strike that patellar tendon just below the patella normal response is contraction of the quadricep and the extension of the knee in picture D you see the Achilles reflex the foot is dorsiflexed at the ankle and the hammer strikes the stretched Achilles tendon and produces plantar flexion and then e is the babisky reflex um you're going to stroke the lateral sole of the foot the toes are going to Fan out and draw back this is normal in newborns but very concerning in an adult patient especially when we are worried about neurologic trauma foreign muscle strength is evaluated on a five-point scale five is normal or full power um with zero being no movement whatsoever and so you can see on this diagram you're going to use a similar tool if not this exact tool to help record muscle strength in your patients but each of your facilities are going to have different tools but it's important that you are assessing it again it's it's assessed on a zero to five scale zero being no strength and five being full strength as far as jiren to logic um considerations it is normal to see changes happen with age normal changes in the neurosystem your patient loses strength and Agility they have a change in their gait posture imbalance as they age their reaction times are going to slow their reflexes are going to decrease their hearing and vision will change their taste and smell will change their Sensations will become much more dull they'll have a change in pain perception their ability to thermoregulate will change and so it is very important as the nurse for you to understand altered responses and provide visual materials um to these older patients you want to talk to them just like you would talk to any other patient we don't need to scream at them just because their hearing has changed you just want to talk slower and in a very clear voice make sure that you're facing them not whispering and just be very simple and concise if you have somebody that is struggling with with one of these changes um in order to determine normal versus abnormal we need to determine previous abilities in order to make a comparison to what we're seeing now we need to know if these changes have taken place over time or if this has been a change since yesterday and a lot of times the family will be the one to help evaluate those changes you need to make sure that you review the diagnostic test listed here on this slide a CT is a cross-sectional x-ray a cerebral angiography um is an x-ray of the cerebral circulation that usually involves contrast um an MRI will allow you to get a more concise image um a pet scan is a nuclear medicine test as well as a spec scan um and then a lumbar puncture is going to allow you to evaluate that cerebral spinal fluid um it will allow you to evaluate whether or not infections are present and things of that nature and we'll look more specifically at the lumbar puncture over on the next slide if your patient is going for a diagnostic test it is very important to make sure that you are educating your patient about the test making sure that consent has been obtained and any preparation for the test or post procedure instructions have been given to your patient and then of course after the test or after the diagnostic procedure you want to make sure that you are evaluating for any potential complications with the CT scan you need an IV site CT scans typically involve contrast so you want to make sure that you assess kidney function assess for any allergies to iodine or shellfish um and then sometimes when a patient receives contrast they'll tell you they feel like um they are just experiencing a flushing or a warming sensation throughout their body um so it's important to to warn them about that ahead of time so that they don't think something is wrong um a cerebral angiography assesses blood flow to the brain and identifies aneurysms and helps get a better look at the vascularity um and so you want to make sure um that that your patient has been formed of what the procedure is for okay most of the time they don't have a clue what you're going to find out from these procedures and so it's always important to educate about that um MRIS one thing to remember with those is that your patient cannot have any sort of mental implant no pacemakers no Orthopedic devices no um artificial heart valves because it could be fatal for the patient if they have some sort of implanted metal device um your nuclear medicine scans your PEC scan and your spect scan sometimes patients will have dizziness and lightheadedness so you want to try to discuss relaxation techniques to decrease anxiety um so that those symptoms will improve but those those procedures will a lot of times involve a very enclosed space just like your MRI will and so you want to make sure that you are educating appropriately each of these procedures are discussed in your book so I would encourage you to go back and read about the procedure and think about the nursing implications that would be important for each of those especially from an education standpoint for your patient a lumbar puncture involves inserting a needle into the subarachnoid space to measure pressure obtain a sample of cerebrospinal fluid for analysis or it can also be used to inject contrast or anesthetics or certain types of medications lumbar punctures should not be done if your patient has increased intracranial pressure because it can increase the risk of brain herniation you also have to be careful if your patient is on an anticoagulant because they can have an increased risk of bleeding that could compress that spinal cord if after a lumbar puncture is done your patient is leaking cerebral spinal fluid if the area does not clot off and seal then it can result in a headache a very excruciating headache and increase the risk of infections for the patient so after a lumbar puncture you want to make sure you educate your patient to lie flat you want to give them fluids and give them pain medications as needed if they get an excruciating headache that we can't get to go away with those other interventions then we can do an epidural blood patch to seal off that hole in the dura and if we have to do that they have to go back to to surgery to have that procedure done um lumbar punctures again involve an informed consent you want your patient to make sure that they have emptied their bladder and bowel because they're going to be side lying in kind of a fetal position um they are going to pull their knees up toward their chin um and kind of Tuck down um but again monitoring for complications after the fact is very very important