1. Electrochemical impulses allow us to detect the what feelings
    • •Thought processes
    • •Sensation
    • •Initiation of proper responses to changes and emotions
    • •Organization of and storage of information for later
    • * Some is conscious activity
    • * Much is reflexive and happens without us even being aware
  2. 2divisions in the nervous system
    • Central Nervous system
    • Peripheral nervous system
  3. Central Nervous system
    • •Brain
    • •Spinal cord
  4. Peripheral nervous system
    • •cranial nerves
    • •Spinal nerves (nerves of the Autonomic nervous system)
    * Nerve cells and nerve fibers
  6. Neurons found in the
    • •spinal cord
    • •Brain
    • •Trunk of the body (protected by bone)
  7. Sensory Neurons
    • •Transmits impulses from the receptors to the CNS
    • •Receptor sites in the skin
    • •Skeletal muscles
    • •joints
  8. Motor Neurons
    • •Transmit impulses from the CNS to “effectors”
    •    : •Muscles
    •      •Glands

    •SENSORY and MOTOR neurons = the PNS
  9. “SOMATIC”
    •Motor neurons from the CNS to the muscle = “SOMATIC”
  10. “VISCERAL”
    Motor neurons to smooth muscle, cardiac muscle and glands = “VISCERAL”
  11. the PNS
    •SENSORY and MOTOR neurons = the PNS
  12. Interneuron’s
    • •Found entirely in the CNS
    • •Used in thinking and learning
  13. Whatis a nerve impulse?
    An electrical change brought about by the movement of ions across the neuron cell membrane!
  14. what are neurons capable of?
    •Neurons are capable of transmitting hundreds to thousands of impulses per second
  15. Spinal Cord
    • Transmits impulses to and from the brain
    • •Is the center for spinal cord reflexes
    • •Is within the vertebral canal formed by the vertebrae
    • •Extends from the foramen magnum of the occipital bone to the disk b/t the L1 and L2
    • •The “central canal” of the spinal cord -small tunnel continuous with the ventricles of the brain
    • •It contains CSF (cerebral spinal fluid)
  16. parts of the spinal cord
    • •7 cervical
    • •12 thoracic
    • •5 lumbar
    • •Sacrum = 5 fused
    • •Coccyx = 5 fused
  17. Spinal Nerves
    • There are 31 pairs of spinal nerve roots!
    • •Exit from spinal cord
    • •The 31 pairs and 12 cranial nerves = PNS
    • •Helps ANS to maintain homeostasis
  18. Spinal Cord Reflexes
    • They do not depend directly on the brain
    • •Include stretch reflexes and
    • flexor reflexes
    • •STRETCH reflex- muscle stretches and automatically contracts (knee jerk reflex)
    • •All skeletal muscles have stretch reflex
    • •Keeps the body upright
    • •Stretch and Reflex both occur without having to think about it- no need for conscious thought
    • •The brain is NOT directly involved
  19. FLEXOR reflex-
    “withdrawal reflexes”- painful stimuli and the response is to pull away
  20. Brain A&P
    • •Medulla
    • •Pons
    • •Midbrain (brainstem)
    • •Cerrebellum
    • •Hypothalmus
    • •Thalmus Cerebrum
  21. Ventricles
    • •4 cavities within the brain
    • •Each contains capillaries called a “choroids plexus”
    • •This forms the CSF (tissue fluid of the CNS) from blood plasma
  22. Medulla
    • Regulates our most vital functions
    • •Cardiac centers that regulate the heart rate
    • •Respiratory centers that regulate breathing
    • •Vasomotor centers that regulate the diameter of blood vessels- so therefore- Bp
    • •There are also reflex centers for cough, sneezing, swallowing, vomiting
  23. PONS
    • •2 respiratory centers in the pons
    • •They work with those in the medulla to produce normal breathing rhythm
    • primarily a reflex center
    • •Regulates the visual reflexes that coordinate the movement of the eyes
    • •Auditory reflexes turn the ear toward sound
    • •“Righting” reflexes- keep the head upright and contribute to balance
  25. Cerebellum
    • Assists with involuntary aspects of voluntary movement:
    • •Coordination
    • •Regulation of muscle tone
    • •Appropriate movements
    • •Maintenance of posture and balance or equilibrium
    • •Uses sensory information provided by the receptors in the inner ear that detect movement in the position of the head
  26. Hypothalmus
    • •Produces ADH (antidiuretic hormone) – increases the reabsorption of water by the kidneys to help maintain blood volume
    • •Produces oxytocin- Causes contraction of the myometrium of the uterus to bring on L&D
    • •Release of GHRH (growth hormone- releasing hormone)- secretes the growth hormone for regulation of growth

    • •Regulates body temperature to assist in homeostasis-
    • •Causes shivering in the cold to help warm the
    • •Sweating to aid in cooling the system•Regulates food intake- responds to changes in the blood nutrient levels or chemicals in the adipose (fat) tissue-Brings on the feeling of fullness/hunger

    •Integration of the functioning of the ANS •Stimulation of “visceral responses” in emotional situations- such as fight or flight in an anxious or fearful situation
  27. Thalmus
    • •Sensory pathways (sensation)- all except OLFACTORY (smell)
    • •Suppresses unimportant sensations- so the cerebrum can focus without distractions of minor sensations
  28. Cerebrum
    • •Cerebral cortex is the surface of the cerebrum
    • •Cerebral cortex is divided into lobes 
    • •FRONTAL LOBES- contain the motor areas that that brings on voluntary movement
    • •Each motor area controls the movement on the opposite side of the body
  29. cerbral lobes
    • •In frontal lobe- usually only the left lobe- BROCA’s motor area- responsible for speech & movements involved in speaking
    • •PARIETAL LOBES- Sensations felt and interpreted
    • •TEMPORAL LOBES- contain sensory areas for feeling, smell, taste
    • •In temporal AND parietal lobes (usually only on the left side)- speech areas involved in the thought that PRECEEDS speech
  30. Meninges & CSF
    • •3 layers of connective tissue that cover the CNS
    • .•OUTER MOST = “Dura Mater”- fibrous connective tissue
    • •MIDDLE = “Arachnoid membrane”- weblike in appearance
    • •INNER = “Pia mater” – very thin connective tissue on the surface of the brain and the spinal cord
    • •BETWEEN the arachnoid membrane (in the middle)- and the pia mater lies the ARACHNOID SPACE- this contains the CSF!
  31. CSF
    • •CSF circulates from spinal cord to subarachnoid space around the brain and spinal cord
    • •CSF is then reabsorbed back to the blood- this equals the rate of production
  32. How can we measure CSF pressures?
    • •Determined by a lumbar puncture- LP or Spinal tap
    • •Can be useful in the diagnosis of meningitis (inflammation of the meninges)
    • •Cultures would be sent for ID of bug and to decipher viral vs. bacterial
  33. CranialNerves
    • •12 pairs- emerge from the brainstem or the brain
    • •Impulses for sight, smell, taste, hearing, equilibrium
  34. AutonomicNervous System (ANS)
    • •Sympathetic
    • •Parasympathetic
    • •They often work in opposition of each other!
    • •Like a push and pull system
  35. SympatheticDivision- (stress)
    • •In the thoracic and some of the lumbar segments of the spinal cord
    • •Dominant in stressful situations- “Fight or flight”
    •    •FEAR
    •    •ANXIETY
    •    •ANGER
    •    •EXERCISE
  36. s/s of sympathetic
    • •Pupils dilate to see better
    • •Increased sweat production for body lubrication
    • •Increased heart rate and force of the heartbeat to ensure blood flow quickly to run faster and gain strength
    • •Vasodilation in the skeletal muscles supplies more O2, the Bronchioles dilate for more air, and the liver changes glycogen into glucose for energy
    • •Digestion is slowed and vasoconstriction in the skin = greater blood flow to vital organs (brain, heart, and muscles)
    • •Neurotransmitters of the Sympathetic division - actylcholine and norepinephrine
  37. ParasympatheticDivision (peaceful)
    • •In the brainstem and sacral segments of the spinal cord
    • •Permits localized responses
    • •Dominates during relaxed, non-stressful situations to promote normal functioning of several organ systems
  38. s/s of parasympathetic
    • •Digestion proceeds normally- with increased secretions and peristalsis
    • •Defecation and urination may occur
    • •The heart beats at a normal resting rate
  39. Aging and the Nervous System
    • •Brain loses neurons, but only in small %’ages
    • •NOT a usual cause of mental impairment in the elderly
    • •More common causes - depression, malnutrition, hypotension and s/e of medications
    • •Minimal forgetfulness - to be expected & a decreased ability for problem solving (usually impairs short term memory)
    • •Voluntary movements become slower
    • •Reflexes & reaction time is slower and greater time is needed to respond
    • •Task performance may take more time to complete
    • •Decreased blood flow to the brain- increases risk of syncope
    • •Altered sleep patterns- they require less sleep and have increased sleep disturbances
    • •Decreased vibratory sense which alters equilibrium and can alter gait
    • •Decreased postural stability which increases fall risk
    • •Pupils are slower to respond and may appear smaller Eyes may be a bit
    • more “jerky” with object following
  40. Tremors
    • Face,
    • hands,
    • head-- common
  41. Nursing assessment
    • •BASELINE assessment of movement, cognition, strength, hearing, speech, smell, taste, vision, sensation
    • •Present function of the client?
    • •Assess the client’s LOC, orientation
    • •Does the client respond to verbal or written instructions?
    • •VS
  42. vital signs
    • •Changes in vital signs usually a late indicator of CNS deterioration•Increased Bp may mean increased cranial pressure
    • •Review widening “pulse pressures”
    • •Irradict pressures and body temps = usually secondary to some sort of brain injury
    • •Pupillary response to light
    • •Assess strength and equality of grips,  movement  & strength of all extremities- compare right to left
    • •Determine the client’s ability to sense touch or pain to the extremities
    • •Obtain a thorough history- physical as well as emotional/cognitive/neuro
    • •Does the client have adequate swallowing, is there dysphagia?
    • •If there is any altered functioning- when did it happen, under what circumstances and what does the client require for assistance
  43. .
    • •Any need for assistive devices or community assistance?
    • •Neuro assessments may have to be done as often as q 15 minutes depending on the client’s situation
    • •Call the physician for any neurological changes and document thoroughlyKeep the client’s safety in high regard
  44. Physical Assessment
    • •Assess LOC 1st
    • •Wakefulness
    • •Alertness
    • •Cooperation
    • •Unresponsiveness to any form of external stimuli
    • •Verbal or not? Slurred speech?
    • •Why?
    • Can be for many reasons: •Medications
    • •Hypoxia•Hypoglycemia
    • •Intoxication
    • •May be psychological- refusal to respond, depression, psychosisMay be dysfunction of the neuro system
  46. Glascow Coma Scale parameters
    • (3 parameters)
    • 1) Eye opening response
    • 2) Verbal response time and is it appropriate 3) Motor response time and pattern
    • See your text for a copy..
  47. Glascow Coma Scale rates/score
    • •Rates are from 3-15
    • •A score of less than 7 = a comatose client
    • •A score of 15 indicates a fully A and O client with full faculties
    • •Often used after surgery, on admission, after a head injury, after an overdose…
    • •If s/p head injury- a score of 13-14 would indicate a MILD head injury
    • •Score of 9-12 indicates a MODERATE injury
    • •Any score below an 8 = SEVERE head injury
  48. what should you do if you use painful stimuli in Glascow Coma Scale?
    •Always document the type of painful stimuli used
  49. any changes in deterioration in Glascow Coma Scale
    • •Report any changes in deterioration PROMPTLY to the dr.
    • •Changes can mean the difference b/t life and death
  50. Eye Opening in Glascow Coma Scale
    • •Can cautiously use painful stimuli if the client does not respond to verbal’s
    • •Sternal rub
    • •Place pressure on the nail beds
    • •Only enough pressure to form a possible response should be used

    **If the client is unable to open eyes because of trauma or swelling- document as a “c” for closed- do not rate the client low on the scale!
  51. Assessing orientation
    • •All of the usual assessment data…
    • **If the client is APHASIC due to a prior stroke- do not assume the client is disoriented!!
    • •Give them yes/no questions- “are you in a museum, are you in the hospital?”, etc… “Is it 2004, Is it June?
    • ”•Can answer shaking the head, squeezing the hand if able, or blinking
  52. confusion & disorientation in Glascow coma scale
    • •Be careful with the terms “Confusion and Disorientation”-
    • •May be confused b.c of long hospitalization
    • •May be able to state year, place and name, but the actual date might be tough
    • •If the client tells you they are in France and it is 1903…
  53. if pt is Disoriented
    • - Correct information reinforced frequently
    • •Calendar or write the date and day on the board
    • •Write- “You are in Cy-Fair Hospital”•Inform patients of procedures
    • •Even if you are merely placing a blanket on them…
  54. if pt Unable to answer due to intubation
    during Glascow coma assessment
    Donot give a low score forresponse- document: intubated and using alternative methodssuch as head nodding, writing, etc..
  55. how is motor response scored in glascow coma scale?
     on using the best arm function for that pt.

    • • If paralyzed, but can blink on command- give a score of “6”- “obeys command”.
    • • If they can voluntarily move a leg, use the leg vs. the arm
  56. “Localizing pain”
    thisis an adequateresponse to pain at a specific area and that the client attempts to push itaway
  57. “Withdrawal form pain”
     is different- this is induction of pain andthe client pulls away from it or withdraws from it
  58. DECORTICATE posturing
    • •Hands and arms withdrawn to the chest-
    • •Wrists and fingers and elbows flexed.
    • •Legs are internally rotated and the feet are plantar flexed (the limbs are to the core)
    • •This indicates significant impairment of the cerebral functioning
    • Image Upload 1
  59. •DECEREBRATE posturing
  60. •Indicates damage to the brainstem-
    • •BOTH the upper and lower extremities are extended and the arms are internally rotated 
    • Image Upload 2
  61. MentalStatus (Exam)
    • •Observing client’s verbal and non-verbal responses
    • •Behavior
    • •Mood
    • •Hygiene
    • •Grooming
    • •Appropriateness of dress, make-up
  62. Eye Assessment
    • •Document size at rest with a mm gauge
    • •If they are large or small- assess of the client has CVA history, have they used eye drops or medications that affect the pupils
    • •Any deviation from complete roundness of the pupil must be documented
    • •Assess the client’s pupillary reaction to light in a dark room
    •     •Reaction = brisk, sluggish or absent.
    • •Any change or one side reaction time is unequal- report
  63. If pt. had equal pupil size but on re-assessment theydo NOT
    thisis an emergency situation!
    • • unequal size in the pupils.
    • 17% of the population has this
    • If so… ask the client if this is normal for them.
  65. Pupillary response “Accommodation”
    • •  refers to the client’s ability to focus as an object moves closer
    • •Hold your finger 18 inched from the clients face, as you move closer, eyes should turn toward the midline and the pupils should constrict
    • •Can’t follow directions? Don’t test for accommodation
  66. Pupillary response
    Assess eyes for the smoothness and coordination of movement
    • •Both eyes should move in the same direction and in a coordinated manner (conjugate gaze)
    • •If the eyes move in a different direction or have an uncoordinated movement (dysconjugate gaze)
    • •Doc. Specifics: “client unable to move right eye laterally”
    • is the involuntary movement of the eyes
    • •Speed varies
    • •Direction varies
    • •Horizontal movement is more common

    •Dilantin toxicity is a common cause and injury to the brainstem
  68. Muscle Function Assessment
    Assessed for
    • symmetry, size and strength
    • •Upper and lower extremities
    • •Compare R/L
    • •The client’s age, history and general physical condition should be regarded
    • •Any chronic neuro deficits or chronic physical ailments? Is it new or changed?
  69. TESTING the upper extremities-
    (deltoid testing)
    • •Ask pt. to raise the arms to the shoulder- resist as you push down on the arms
    • •Bicep testing- flex the arm at the elbow and bring the palm toward the face- have the client resist as you attempt to straighten the arm by pulling on the forearm
    • •Then ask the client to “make a muscle”, with the arm slightly flexed, ask the client to straighten the arm while you resist the movement
  70. TESTING  Hand grasps
    • •Tested by having the client squeeze your fingers (cross your middle and index fingers to avoid being injured by the client)- Assess the strength and is it equal R/L
    • •IF the client does NOT release the grasp when told to it is considered a “reflex grasp” not a response to command
  71. A“reflex palmargrasp”:
    • • may indicate a pathological condition in the frontal lobe
    • •Also ask pt. to raise both arms out to the side at the shoulder with the palms upward - keep eyes closed- do the arms drift?
    • •If so… a downward drift or rotation of the palms downward indicates impairment of the opposite side of the brain
  72. Assess leg muscles
    • •Start with the iliopsoas muscle
    • •Place hand on the thigh, ask them to raise the leg, flexing at the hip
    • •Hip adductors are tested by having the client bring the legs together against the hands
    • •Have pt. move legs apart against the hands
    • •Tests the hip abductors and the gluteal muscles (medius and minimus)
    • •Have pt. straighten the leg at the knee after bending at the knee- this tests the quadriceps Have pt. move the toes toward the head tests dorsiflexion
  73. Babinski’s Reflex
    •Stroke the sole of the foot- normal response is flexion of the great toe

    •If the great toe extends & toes fan out= Neuro dysfunction-suspected in the client more than 6 months of age
  74. Gait Assessment
    • •Walk a straight line? Steady or unsteady?
    • •Stagger, weave, or bump into objects in the pathway?
    • have the client stand with legs together and eyes closed
    • NEGATIVE test = minimal swaying for up to 20 seconds
    • POSITIVE test = one who sways or moves to one side- this may indicate in cerebellar dysfunction (a positive response in the older adult is expected due to the normal aging of the cerebellum)
  76. Cranial Nerve Assessment
    is not included in routine assessment!

    • 1-OLFACTORY nerve can be done by having the client identify common scents
    • 2-OPTIC- read something, identify a picture
    • 3-OCCULOMOTOR- Pupils for the reaction of light
    • 4-TROCHLEAR- follow the finger while in front of the client and from side to side
    • 5- TRIGEMINAL- lightly touching the clients face to check for sensation
    • 6- ABDUCEN- (same as trochlear)
    • 7- FACIAL – have the client smile, frown, wrinkle forehead
    • 8- AUDITORY- conversing with the client can assess this- change the volume of the voice - have the client ambulate- do they have difficulty with balance
    • 9/10- GLOSSOPHARYNGEAL and VAGUS- assess gag reflex, ask the client to say “ah” 11- SPINAL ACCESSORY- ask the client to shrug the shoulders against resistance
    • 12- HYPOGLOSSAL- have the client stick out the tongue and move it from side to side- assess the symmetry and movement
  77. VS lateindications of increasing intracranial pressure
    • Bradycardia,
    • increased systolic Bp,
    • widening pulse pressure
  78. •Correlate assessment findings with
    the patient’s remainder of the assessment (physical, etc…)
  79. Diagnostic Testing
    • •SED rate
    • •Increased WBC’s
    • •Can indicate infection such as meningitis
    • •Changes in hormone levels- prolactin and cortisol can indicate dysfunction of the pituitary gland as in a brain tumor
  80. Diagnostic testing
    • CSF tested for glucose, protein, WBC’s, immunoglobulin levels, C/S
    • •Assessment for color and clarity- •Document what was done, by who and how it was tolerated
    • •Send all samples to the lab ASAP
    • •Needle placed at the level of L3-L4 or L4-L5 in the adult
  81. LP Nursing Care
    • •Informed consent
    • •Pt. will be anxious; may need additional assistance to help hold the client, especially children or infants
    • •Pt. will need to side-lie in fetal position with the legs into the chest
    • •The back is placed to the closest edge of the bed to Dr
    • .•If the side-lying is impossible- they can sit upright curled over a bedside table
  82. AFTER the LP
    • •- should remain on bedrest
    • •Laying flat for 6-8 hours or as ordered
    • •This helps keep the CSF from leaking from the puncture site (this can cause severe HA)Follow orders and educate
  83. Normal CSF
    • WBC 0-8,
    • clear
  84. CSF Testing
    • •Xrays
    • •CT
    • •MRI
    • •MRA
    • •Angiogram
    • •Myelogram
    • •EEG
  85. CT-
    • •CT- remember with and without contrast
    • •What do you need to educate?
    • •What do you need to evaluate?
    • •The pt. may feel warmth at the groin site (with)
    • •Assess for n/v, sob, itching, diaphoresis and report immediately if with contrast
    • •Sedation may be required or pain meds prior to the test
  86. MRI-
    • •review education
    • -May be with and without contrast
  87. MRA
    Canvisualize bloodvessels and assess blood flow without the aggressiveness of an angiogram
  88. Angiogram
    • •X-ray study of blood vessels
    • •Local anesthesia is injected
    • •Catheter is inserted in the femoral artery and advanced until the contrast medium can be injected into the cerebral vessels
    • •Client receives a C/L diet before the test
    • •BUN and CR is assessed
    • •Pt and PTT b/c bleeding is a risk due to the large puncture into a large artery
    • •Sedation is usually given prior
    • •May feel heat sensation and metallic taste
    • •Client must lie still
  89. After Angiogram
    • •After testing- pressure to insertion sit and laying flat for 6-8 hours, may turn side to side but affected leg must stay still and flat
    • •Assess frequent VS and circulation and neurovascular of the leg distal to the insertion site (decreased sensation or pulse may indicate clot in the femoral artery- call Dr. ASAP)
    • •Increase po fluids and may need increase in IVF’s
  90. Myelogram
    • •Xray of the spinal canal
    • •Contrast into the subarachnoid space
    • •Client may be moved in various positions  and films are taken
    • •Bedrest with minimal HOB elevation afterward
    • •S/E may be seizure- assess frequently and keep the client safe
  91. EEG
    • •Electrodes to the scalp to assess electrical activity of the brain
    • •Sedatives are usually withheld- especially if it is to r/o seizure activity
    • •Anticonvulsants may be stopped prior to the testingMonitor for safety
  92. Nursing measures for pt. with alteration in mental status/movement
    • •PROM
    • •Footboards and high top tennis shoes
    • •Turn q 2 hours or more often
    • •Assess skin for breakdown
    • •Functional positioning
    • •Splints if needed
    • •Call light in reach with frequent checks
    • •Talk to your patient!
    • •PO fluids should be encouraged and increased
    • •Check the puncture site for leaking and report to the Dr.Assess for HA and have an order for pain med’s if needed
  93. assessment for for pt. with alteration in mental status/movement
    • •Assess orientation and speech ability, aphasic?
    • •DO you need alternative sources for communication?
    • •Nutritional assessment
    • •Swallowing assessment
    • •Aspiration precautions?
    • •Need thickeners, HOB up?
  94. Doll’sEyes Assessment
    - Normal response- eyes move opposite of direction head is moved (Doll’s eyes present)

    -Abnormal response- head moved- eyes stay fixed (Doll’s eyes negative)
  95. •Occulovestibular reflex-
    • -Increase HOB to 30 degrees-Absence of any eye movement may indicate brain lesion
    • •Pupils fixed = brain damage
    • •One fixed and one dilated = IICP
    • •Both constricted- Pons damage
  96. Brain Tumors
    •Growth in the brain or meninges

    • •Neoplastic   (CA)
    • •Benign
    • •May be primary or metastatic
    •    •Primary brain tumors rarely met
    •    •When they do… typically ot the spine
  97. importance of location with brain tumors
    • •Some benign brain tumors can be fatal!
    •   •If they are at the brainstem
    • •Some malignant tumors are not necessarily fatal:
    •   -Frontal lobe may not be
    • -So it all about LOCATION LOCATION!
  98. s/s of brain tumors
    • •There may not be any until the tumor is quite large
    •   - ex. Slow growing “meningimas”
    • •s/s are r/t location
    • •Seizures
    • •Motor/sensory deficits
    • •Headache due to pressure and IICP
    • •Visual changes
  99. Brain tumor Testing
    • •CT
    • •MRI
    • •MRA
    • •Serum hormone levels if in the pituitary
    • •Biopsies -Needle and open-Some require a craniotomy
  100. care for brain tumor pt's
    • •These folks do not usually need pain control with narcotics!
    • * Control symptoms (seizures for example)
    • •Decrease IICP (Decadron)
    • •Surgical removal?
    • •Radiation therap
    • y•Brachytherapy
  101. Whatis Brachytherapy?
    • •Placement of small catheters into the tumor itself
    • •Radioactive particles are placed into the catheters
    • •This goes directly to the tumor tissue
    • •This is radioactive 
    •     private room and
    •     TONS of education
  102. Howdo we go directly to the tumor for brachytherapy?
    •Stereotactic placement-Small metal frame is placed onto the clients skull-Tumor borders id’s via MRI-Radiation focus on the tumor or catheters are placed-This limits exposure to healthy brain tissue
  103. Chemo for brain tumors
    • •It is difficult to penetrate the blood brain barrier (BBB)
    • •Very large doses are needed to penetrate
    • •Not always tolerated well by the other organs!
    • •Not always an option if pt can't tolerate it
    • •Investigational studies still on-going
  104. Complicationsof brain tumors
    • •Seizures
    • •Memory impairmen
    • t•Gait issues/ataxia
    • •Headaches
    • •Cognitive changes
    • •Hemiparesis
    • •Aphasia
    • •Visual changes/blindness
    • •Coma/death
  105. Intracranial surgery
    • •Educate what to expect before, during and after
    • •FIRST: biopsy done to id neoplastic or benign
    • •Patient usually under general anesthesia
    • •Local may only be used though…
    • •At times- during surgery the patient needs to be awake and cooperative
    • •Think of the anxiety!!!
  106. types of intracranial surgeries
    • •Debulking- removal of all or part of the tumor
    • •Craniotomy- surg. opening into the skull
    • •Craniectomy- removal of the cranial bone
    • •Cranioplasty- repair of the bone or prosthetic placement
  107. Debulking
    - removal of all or part of the tumor
  108. Craniotomy
    - surg. opening into the skull
  109. Craniectomy
    - removal of the cranial bone
  110. Cranioplasty
    - repair of the bone or prosthetic placement
  111. Intracranial surgery Pre-op
    • •Lab testing, diagnostic studies
    • •Baseline physical and neuro assessment (thorough assessments!)
    • •Education- patient and family
    • •LISTEN!
    • •Tell them the approximate time for surgery- some can be VERY long
  112. what do you prep pt for in pre-op intracranial surgery?
    • •Prep the patient for hair removal- this can be a BIG deal
    • •Face will be swollen, eyes may be swollen shut
    • •Peri-orbital bruising
    • •There may be drains, bolts, shunts…
    • •Or maybe notPrep them for possibilities if the doc syas it could happen
  113. intracranial surger post-op
    • •VERY careful and close monitoring of VS, neuro’s, physical assessment
    • •Neuro checks will probably be q 15 minutes, then q 1 hour for 24 hours or so•Any changes- report ASAP!
    • •CT after surgery- assessing for cerebral edema
    •    •CSF leak
    • •Spinal headache
  114. CSF leak assessment
    • •Assessment for CSF rhinorrhea
    • •CSF ottorhea
    • •Can happen after brai
    • n surgery
    • •Testing of secretions- glucose and protein
    • •May require surgical repair- or endoscopic repair
    • •Use of fibrin glues a possibility to stop the leak
  115. CSF leakage after LP or spinal surgery
    • •Leak at puncture site
    • •Can also happen after steroid injections into the epidural space
    • •Treatment  is bed rest, hydration, steroids or an epidural blood patch
  116. Epidural Blood Patch
    • •A small amount of the patient's blood is injected into the epidural space near the site of the original puncture
    • •The resulting blood clot then "patches" the meningeal leak.
    • •The procedure carries the typical risks of any epidural puncture. However, it is effective and further intervention is rarely necessary.
  117. how is Epidural Blood Patch done?
    •An epidural needle is inserted into the epidural space at the site of the cerebrospinal fluid leak and blood is injected. The clotting factors of the blood close the hole in the dura.

    So, the autologous blood does not "repair" the leak, but rather treats the patient's symptomology.
  118. Spinal disorders
    • •Herniated disks
    • •Spinal stenosis
    • •Spinal cord injuries
    • •Spinal shock
  119. Herniated disks
    • •The intravertebral disk moves out of position
    • •Can be due to lifting, fall, mva, etc.
    • •Causes pain and parasthesias along the nerve path affected
    • •Displacement causes pressure on the nerve roots
    • •Causes muscle spasms
    • •May have decreased ROM secondary to pain
    • •Numbness/tingling in limbs
    • •Weakness and atrophy = sure indicator of nerve involvement
    • •Limping on affected leg may cause trouble walking on the hell to the toe
    • •Muscle spasms are common
  120. Herniated disk locations
    • •Rare to have herniated thoracic disks!
    • •Why?- this part of the spine is the least moveable so less likely to be injured

    •L-spine herniation causes pain to the low back radiating to one leg
  121. What does Herniation to L5-S1 cause
    • may cause bowel and bladder incontinence
    • •This is a medical emergency!
  122. Herniated disk testing
    • •MRI for spinal cord abnormalities
    • •May be with/without contrast
    • •If patient had prior disk surgery- MRI needed to differentiate b/t scar tissue and the herniated disk
    • •Myelogram if cannot tolerate MRI or a closer study is needed
  123. Herniated disk Tx
    • •Deep massage to decrease spasms and increase ROM
    • •TENS unit (transcutaneous electrical nerve stimulator) to the skin around the site
    •       •Current penetrates site and decreases spasms and pain (noninvasive)
    • •Cervical traction may be ordered
    •     •Safety
    • •Valium may be prescribed- but watch for addiction
    • •NSAIDS for inflammatio
    • •Oral steroids- short term use and taper when discontinuing (over 1 week)
    • •Serum glucose monitoring
    • •Epidural injections- steroids and long acting anesthetic into the epidural space
    • •Short term opioids for pain
    •      •Increased risk for addiction
  124. Traction
    • Cervical- head in a sling to pull head away from shoulders
    • •This slightly separates vertebral bodies to allow disk to slip back into place

    Lumbar traction- doable but not usually effective
  125. why are muscle relaxants often ordered w/ traction for herniated disk?
    because chronic spasms can cause tearing and scarring
  126. Surgical management for herniated disk
    • •Laminectomy- removal of one or more of the “laminae”
    • •This is the flat piece of bone on either side of the vertebrae
    • •Diskectomy- removal of the entiree disk (herniation)
    • •Spinal fusion- bone graft to fuse two vertabrae together if unstable
  127. Surgical management complications
    • •Hemorrhage- AIRWAY!
    •     •More common s/p cervical deskectomy
    • •Monitor all surgical sites for bleeding s/s of infection
    • •Monitor VS closely
    • •Monitor neuro
    • •Monitor for movement and ROM as ordered by Dr
    • •Be sure to assess for CSF leakage
    •      •Will appear clear or slightly blood tinged
    • •Monitor the donor site if bone grafting was done
    • •I/O
    • •Side effects of medication, anesthesia.
  128. what Surgical management complications need to monitor for
    • Monitor all surgical sites for bleeding s/s of infection
    • •Monitor VS closely
    • •Monitor neuro
    • •Monitor for movement and ROM as ordered by Dr
    • •Be sure to assess for CSF leakage    
    •      •Will appear clear or slightly blood tinged

    • •Monitor the donor site if bone grafting was done
    • •I/O
    • •Side effects of medication, anesthesia.
  129. Spinal Stenosis
    • •Spinal canal compresses the cord
    • •Can be caused by arthritis
    • •Causes pain and weakness in the spins and in the limbs
    • •Laminectomy can be done to decrease pressure on the spinal cord (see post opcare previously discussed)
  130. Spinal Cord injuries
    •Damage = tear, cut, bruise, edema, bleeding into cord•Or complete severing of the cord
  131. S/S of spinal cord injuries
    • •Decrease or loss of sensory/ motor function below the level of injury
    • •s/s will depend on the extent of injury and the level of the injury
  132. Completeinjury and incomplete lesion
    (spinal cord injury)
    • •Complete injury- no motor or sensory function below the level of injury
    • •Incomplete lesion- some function remians -May not be truly useful-May cause pain

    * C and L are most commonly injured, more often than T and S
  133. S/Sof a cervical injury
    • •Can affect all 4 extremities
    • •Can cause paralysis, parasthesias, impaired respirations, loss of bowel and bladder

    • •Quadraplegia- paralysis of all 4 extremities
    • •Quadraparesis- weakness in all 4
  134. S/S of a cervical injury by area
    •Injury C4 and above- usually fatal b/c muscles for breathing are paralysed

    •C4-C5- most require mech. ventilation
  135. Thoracic ,Lumbar, Sacral Injuries
    •Affect bowel, bladder and legs

    • •Paraplegia- paralaysis of legs
    • •Paraparesis- weakness of legs

    • •Sacral Injuries
    • - affect bowel and bladder
    •     -Causes incontinence
    • -May also affect foot function
  136. Spinal Shock
    • •Affecting ANS and SNS
    • •Causes vasodilation, hypotension, bradycardia
    • Spinal shock can last weeks or months after the injury occurs
    •  Be aware and assess
    • •Assess often
  137. s/s spinal shock
    • •Dilation of blood vessels allows more blood under the skin•Causes hypothermia b/c the blood cools•Many will be unable to maintain body temp
    • •Urine and feces is typically retained
    • •Patients will require assistance
  138. Complicationsfor spinal cord injury patients
    • 1)Infection
    • 2)DVT
    • 3)Orthostatic hypotension
    • 4)Skin problems
    • 5)Renal complications
    • 6)Depression, substance abuse
    • 7)Autonomic Dysreflexia
  139. spinal cord injury infection
    • - decreased cough effort-mech. Ventilation can lead to pneumonia
    • -Indwelling catheters UTI
    • -Bed sores
    • -S/p surgery infections
    • -Hardware infections
  140. spinal cord injury DVT
    • •Lack of lower extremity movement
    • •Lack of movement all together
    • •This inhibits circulation and increases risk of DVT
    • •TED’s and SCD’s
    • •SQ heparin, lovenox, etc…
    • •Assess for s/s of DVT
  141. spinal cord injury Orthostatic hypotension
    • •No muscular function in legs = lack of movement = decreased venous return to the heart
    • •Impairment of vasoconstriction = blood pooling in the legs
    • •Patients feel fait with movement
    • •Gradual elevation of the head!!!
  142. spinal cord injury Skin problems
    • •Bed sores and pressure ulcers
    • •Skin infections
    • •Patient may not be able to feel pressure areas due to lack of sensation and inability to shift weight
    • -Protect bony prominences
    • -Turn frequently and CAREFULLY-ASSESS carefully
  143. spinal cord injury Renal complications
    • •UTI’s secondary to indwelling or intermittent catheterization
    •  •Urinary reflux can cause permanent damage to the kidneys
    • SO can chronic UTI’s and untreated UTI
  144. spinal cord injuryDepression, substance abuse
  145. spinal cord injury Autonomic Dysreflexia
    • •Life has changed dramatically!
    • •Pain meds can = addiction
    • •Also- tolerance
    • •Many will self-medicate with street drugs, alcohol
    • •Loss of friends and a will to live
    • •Many hospitalizations, surgeries
    • •Counseling for patient and family
  146. spinal cord injury Autonomic Dysreflexia
    • •Usually only with injuries above T5-T6
    • •Injury impairs normal equilibrium between SNS/PNS (ANS)
    • •Noxious stimuli below the injury can cause activation of the SNS
    • •Typically happens after spinal shock
    • •FYI- more common in males (?)
    • •So what is this “noxious stimuli”?
  147. noxious stimuli in autonomic dysreflexia
    • •Can be anything irritating:
    • -Bladder distention*
    • -Bowel impaction
    • -UTI-Ingrown toenails
    • -Pressure areas, ulcers, DVT
    • -Pain, including invasive testing
    • -Labor, menstruation
  148. happening in autonomic dysreflexia
    • SNS is stimulated causing:
    • •Pale, cool, goose-bump flesh
    • •Vasoconstriction is happening below the level of injury
    • •Bp increases- can be > 300mm/Hg Systolic
    • PNS: vasodilation, flushing
    • -Diaphoresis above the injury-Brady < 30 bpm
    • -Vasodilation causes nasal congestion, head ache
  149. what to do if we suspect a spinal cord injury
    • •Immobilize the patient
    • •ER treatment and testing STAT
    • •Treat any symptoms to stabilize first
    • •Treat injury based on severity and level
    • •Careful monitoring of airway and VS
    • •IV NS for fluid replacement and for hypotension risks
    • •Be wary of pulmonary edema with diligent IVF’s

    • •Assessment of Bp
    • •May require vasoactive drugs for stabilization
    • •May require methylpredisolone for inflammation
    • •Tests will then begin to assess for injury location and severity
    • •Remember- in an emergency we can do what needs to be done without consent!
  150. Respiratory management for spinal cord injury
    • •This is a biggie!
    • •Above C4-5- some degree of impairment
    • •Some may be able to breath on their own but it can become compromised due to swelling later on
    • •Edema in the cord can cause inflammation and impairment above the level of injury
    •    •This is usually temporary
    • •Fatigue and overuse of accessory muscles can impair/compromise breathing
    • •Watch for shallow breathing!
    • •Fatigue when breathing will most likely cause anxiety and fear
    • •Watch for any changes!
    • •May require mech. ventilation
  151. GI management for spinal injury
    • •Absence of bowel sounds is normal at first
    • •Paralytic ileus- paralyzed  = no movement in GI tract
    • •Oral and enteral feedings not started until we have bowel sounds!
    • •May require swallow studies first
    • •Metabolic needs are going to be increased due to labored breathing
    • •May require TPN feedings
  152. GU management for spinal cord injury
    • •Indwelling catheter (foley)??
    •     •Increase risks for infections!
    • •Infections and chronic cathetrization can cause damage to the kidneys long-term
    • •Bladder training later on
    • •With all patients able to control urination
    • •Remember dignity!
  153. Immobilization
    • •C-spine must be immobilized with a C-collar if injury is suspected
    • •Then possible immobilization with a halo (skeletal traction)
    • •Remember that these attach with 4 pins and poles to a shoulder vest
    • •Keeps neck and head immobile
    • •Does not confine patient to the bed!
  154. Surgical management of spinal cord injury
    • •To stabilize and relieve pressure on the cord
    • •Stabilization can lead to early mobilization
    • •May require halo
    • •May require rod placement if T and L fractures involved
    • •Surgery depends on extent and region of the fracture or injury
  155. Education for spinal cord injury
    • •There is so much!
    • •All we have already discussed and inform the family as well
    • •Educate to start on simple tasks first
    • •Follow orders strictly!
    • •Safety education
    • •Community resources, home health, social services, etc…
  156. Degenerative neuromuscular disorders
  157. Parkinsons-
    • •Please review notes
    • •Remember excessive ACH that is chronic and degenerative
    • •Tremors, rigidity and bradykinesia
    • •Tremors may be more evident when at rest or grasping an object
    • •Gradual onset
    • •Stooped posture, pill rolling
    • •Safety is a huge deal!
    • •Blinking is diminished
    • •Mask-like expression
    • •c/o generalized weakness and fatigu
    • •c/o constipation, ortho hypotension, drooling, dysphagia, ANS issues
    • •Mental function will become slowed
    • •Teach safety and med ed
  158. Parkinsons Meds
    • •Artane- blocks ACH, decreases tremors, salivation
    • •Causes dry everything and to an excess sometimes!
    • •Monitor I/O
    • •Increase po fluids if ok
    • •Artificial tears and oral lubrication

    • •Symmatrel- production of dopamine
    • •Causes leg edema, hypotension, confusion
    • •Safety education
    • •Elevate legs
    • •Monitor VS and I/O
  159. Levadopa
    • •Levadopa- converts into dopamine in the brain
    • •Tremors decrease, as does rigidity and bradykinesia
    • •Can cause n/v, assess I/O
    • •Take 15 minutes before meals
    • -Protein breakdown is often slowed
    • -Educated may need to minimize protein intake
    • * L/Carbidopa- (Sinamet) combo to lessen side effects!
  160. parkinsons Meds continued
    • •Combo of drugs may lessen side effects…
    • •Mirapex- improves motor function but can cause sleepiness, weakness and confusion
    • •Eldapryl- blocks dopamine metabolism to increase dopamine to CNS
    • •Comtan- prevents levadopa breakdown
    • •Used with Sinamet- turns urine orange and can cause hallucinations and confusion
  161. Huntington’s Disease
    • •Progressive, hereditary, degenerative
    • •Child of affected parent- 50% chance of obtaining disease
    • •Lifespan after dx.- about 10-20 years tops
  162. s/s of Huntington’s Disease
    • •s/s slow and progressive
    • •Inappropriate movements, uncontrolled
    • •Personality changes, mood swings
    • •Paranoia, dementia and possibility of violent behavior
    • •Invol. Movements start in the arms, face, neck and progress
    • •Hesitant speech, eye blinking, irregular trunk movement, constant motion
    • •May disappear with sleep
    • •Dysphagia, increased aspiration risks
    • Depression/suicide in early stages of diagnosis
  163. Huntington's disease testing
    • •Based on clinical exam
    • •May not have symptoms until in their 30’s or 40’s
    • •Treatment is to minimize symptoms and prevent complications
    • •Antipsychotic meds such as haldol
    • •Carbidopa/levadopa for neuro protection
  164. Genetic testing for Huntington's Disease
    • •APP gene – Amyloid Precursor Protein
    • •On Chromosome 21
    • •Mutation of chromosome 21 also seen in early onset familial Alzheimer’s
    • •Down’s Syndrome- extra version of chromosome 21
    • •FYI
  165. Nursing Management for Huntington's Disease
    • •Devastating diagnosis when they research disease
    • •Be calm
    • •Cooperation may be difficult if patient already with dementia or personality changes
    • •Patients can harm self due to invol. Movements
    • •Risk for aspiration
    • •Soft foods and sit upright with and after meals
    • •Swallow studies
  166. Alzheimers
    • •Again- review info
    • •More common in women- progressive loss of intellectual functioning
    • •Why? Genetics- chromosome 21 and the sequence of gene s (there are about 225 genes in ch. 21)
    • •Tangled neurofibers in the brain and plaque formation
    • •The younger diagnosed- the faster it tends to progress
  167. 3 Stages of Alzheimers
    • -Early- forgetfulness (2-4 years)
    • -Middle (2-12 years) progressive deterioration
    • -Late (progression to complete dependency)
    • * Death often due to complications such as aspiration, pneumonia, etc…
  168. Alzheimers Treatment
    • •No cure•Minimize effects
    • •Safety!
    • •Medications- Cognex-  breaks down ACH
    • •Might take many weeks before any effects
    • •Aricept- fewer side effects
    • •Antidepressants, antipsychotics, anti-anxieties
  169. Trigeminal Neurlagia
    • •Neuropathic disorder of the trigeminal nerve
    • •Causes episodes of intense pain to eyes, lips, jaw, scalp, forehead
    • •Usually develops after age 50
    • •Slight touch or breeze can cause electric-like shocking pain
    • •Why? They think blood vessels compress the trigeminal nerve near the connection with the pons
    • •Can be due to tumor, aneurysm, cysts
    • •Dx.- based on eliminating other possibilities like a CVA
  170. Trigeminal Neurlagia Treatment
    • •No cure
    • •Surgery- microvascular decompression, but can cause numbness
    • •Can minimize attacks with ice packs, warm packs
    • •Rest keep stress low

    • •Most recover without treatment  with signs of improvement in about 10 days after onset
    • •FYI- the forehead may not be affected on that side because the forehead is inervated by both sides of the brain
  171. Trigeminal Neurlagia Meds
    • •Anticonvulsant meds are helpful
    • •Oxycodone and methadone for pain when all else fails!Botox injections
    • •Anti-inflammatories
    • •Antivirals
  172. Bell’sPalsy
    • •Paralysis of the facial nerve, drooping of the face
    • •Cannot control facial muscles on the affected side
    • •This is the most common disorder involving only one nerve (nervus facialis) cranial nerve VII
    • •Unilateral involvement rapid onset with complete or partial palsy in one day
    • •Thought to be due to inflammation leading to swelling of the nerve
  173. Bell’s Palsy Causes / Treatment
    • •Causes (possible)- tumor, meningitis, CVA, DM, head trauma, inflammatory disorders
    • •Also- some research shows that HSV-I was identified as a major cause
    • •HSV-I and Varicella Zoster are linked
    • •So here is why we often give an anti-viral medication after dx. Is made
    • •Corticosteroids may be ordered too (prednisone)
  174. Bell’s Palsy Complications
    • •Chronic loss of taste
    • •Chronis facial spasms
    • •Corneal infections (cover the eye with tape when sleeping)
    • -May need eye moistening drops like artificial tears
    • * Some may have complete facial para
  175. Pituitary Adenoma
    • •Tumor in the pituitary gland
    • •These account for about 10% of intracranial neoplasms
    • •Often remain undiagnosed
    • •About 6-24% of adults autopsied had pit. Adenomas
  176. Pituitary Adenoma Types
    • •Thyrotrophic adenoma- secrete TSH  causing hyperthyroidism
    • •Somatatrophic adenoma- secrete GH- causing gigantism
    • •Prolactinomas- most common- secrete prolactin causing galactorrhea, amenorrhea, infetility and impotence
  177. Pituitary Adenoma Dx
    • •Usually starts with visual problems due to compression of the optic nerve
    • •These tumors are usually 10 mm in size or >- “macroadenomata”
    • •May be diagnosed based on the excessive hormone secretions
    • •Prolactinomas frequently diagnosed during pregnancy
    • - Progesterone increases the tumor’s growth rate
  178. Pituitary Adenoma Treatment
    • •Dopamine agonist medications (for prolactinomas)
    • •Large tumors- radiation or surgical removal/debulking
    • •Thyrotrophic adenomas and some somatotrophic adenomas - might respond to octreotide (Sandostatin)- which inhibits secretion of GH
  179. Acoustic Neuroma
    • •AKA-Vestibular Schwannoma
    • •Benign primary intracranial tumor
    • •CN VIII- Vestibulocochlear nerve
    • •These can occur sporadically
    • •Solitary tumor- originates in the nerve within the auditory canal
    • •As it grows- extends between cerebellum and pons
  180. Acoustic Neuroma Dx
    • •CT/MRI
    • •Audiology using air conduction
  181. Acoustic Neuroma Treatment
    • •Treatment is usually radiotherapy and surgical removal
    • •Sugery- vestibular nerve removal- hearing is affected on that side, but the other ear will overcompensate…
    • •PS- after surgery- facial nerve damage can occur
    • •Because these are slow growers, they may just watch closely with MRI (yearly)
    • •Small ones can shrink spontaneously!
    • •Even after surgery- they can grow back- yearly MRI- life
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