Medical-Surgical Nursing: An Integrated Approach, 2E Chapter 25

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Medical-Surgical Nursing An Integrated
Approach, 2E Chapter 25

• NURSING CARE OF THE CLIENT NEUROLOGICAL SYSTEM

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The Human Nervous System

• Its purpose is to control all motor, sensory,
  autonomic, cognitive, and behavioral activities.
• This is accomplished by coordination and
  initiation of cellular activity through the
  transmission of electrical impulses and various
  hormones.

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The Nervous System Structure

• The nervous system is divided into
• The central nervous system, consisting of the
  brain and spinal cord.
• The peripheral nervous system, which consists of
  the cranial nerves and spinal nerves.
• Basic functional unitneuron
• The autonomic nervous system, which is part of
  the peripheral nervous system and consists of
  sympathetic and para-sympathetic systems.

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The Brain

• Composed of gray matter and white matter, the
  brain controls, initiates, and integrates body
  functions through the use of electrical impulses
  and complex molecules.

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Physiology of the Brain

• The brain is contained within the skull, or
  cranium.
• Three coverings of the brain, called the
  meninges. They are the dura mater, arachnoid
  mater, and pia mater.

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The Brain Hemispheres

• The right side receives information from and
  controls the left side of the body. Specializes
  in perception of physical environment, art,
  music, nonverbal communication, spiritual
  aspects.
• The left receives information from and controls
  the right side of the body. Specializes in
  analysis, calculation, problem solving, verbal
  communication, interpretation, language, reading,
  writing.

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The Spinal Cord

• A continuation of the brain stem.
• Exits the skull through the foramen magnum, an
  opening in the base of the skull.

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Cerebrospinal Fluid

• Provides for shock absorption and bathes the
  brain and spinal cord.

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Peripheral Nervous SystemCranial Nerves

• Twelve pairs of cranial nerves have sensory,
  motor, or mixed functions.

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Cranial Nerves
Olfactory Sensorysmell Optic SensoryVision Oculomotor Motor Pupil Constriction Trochlear Motorupper eyelid elevation
Trigeminal cornea, nose, oral mucosa mastication Abducens Motor Extraocular eye movement Facial Motor (facial muscles) Sensory (taste) Acoustic Sensory Hearing Equilibrium
Glosso- Pharyngeal Taste Swallowing Vagus Motor and Sensory Spinal Accessory Motor Hypoglossal Tongue Movement
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Peripheral Nervous SystemSpinal Nerves
NERVES NUMBER OF PAIRS

• Cervical 8
• Thoracic 12
• Lumbar 5
• Sacral 5
• Coccyx 1

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Peripheral Nervous SystemAutonomic Nervous
System

• Main function is to maintain internal
  homeostasis.
• Two subdivisions of ANS
• The sympathetic system (activated by stress,
  prepares body for fight or flight response).
• The parasympathetic system (conserves, restores,
  and maintains vital body functions, slowing heart
  rate, increasing gastrointestinal activity, and
  activating bowel and bladder evacuation).

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Neurologic Assessment Health History

• Pain
• Seizures
• Dizziness (abnormal sensation of imbalance or
  movement) and vertigo (illusion of movement,
  usually rotation)
• Visual disturbances
• Weakness
• Abnormal sensations

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Neurologic Assessment

• Cerebral function mental status, intellectual
  function thought content, emotional status,
  perception, motor ability, and language ability
• Note the impact of any neurologic impairment on
  lifestyle and patient abilities and limitations
• Agnosia is the inability to interpret or
  recognize objects seen through the special
  senses.
• Motor system posture, gait, muscle tone and
  strength, coordination and balance, Romberg test
  
• Sensory system tactile sensation, superficial
  pain, vibration and position sense
• Reflexes DTRs, abdominal, and plantar (Babinski)

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Techniques Eliciting Major Reflexes
(A) Biceps reflex. (B) Triceps reflex. (C)
Patellar reflex. (D) Ankle or Achilles reflex.
(E) Babinski response.
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Figure Used to Record Muscle Strength

• 5, full range of motion against gravity and
  resistance 4, full range of motion against
  gravity and a moderate amount of resistance 3,
  full range of motion against gravity only 2,
  full range of motion when gravity is eliminated
  1, a weak muscle contraction when muscle is
  palpated, but no movement and 0, complete
  paralysis.

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Gerontological Considerations

• Important to distinguish normal aging changes
  from abnormal changes
• Determine previous mental status for comparison.
  Assess mental status carefully to distinguish
  delirium from dementia.
• Normal changes may include
• Losses in strength and agility changes in gait,
  posture and balance slowed reaction times and
  decreased reflexes visual and hearing
  alterations deceased sense of taste and smell
  dulling of tactile sensations changes in the
  perception of pain and decreased
  thermoregulatory ability

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Pupil Size

• Normal range 2 - 6 mm
• Drugs pinpoint pupils
• Increased intracranial pressure pupils begin to
  dilate
• Dilated and fixed, poor prognosis

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Glascow Coma Scale

• Eye Opening
• Spontaneous                       4To
  Voice                            3
• To Pain                               2
• None                                   1
• Best Verbal
• Oriented                             5
• Confused                            4
• Inappropriate Words           3
• Incomprehensible Sounds 2
• None                                   1
• Best Motor
• Obeys Commands             6
• Localizes Pain                     5
• Withdraws to Pain              4
• Flexion to Pain (decorticate)               3
• Extension to Pain (decerebrate)          2
• None                                  1

• Score BEST response in each category
• Highest score 15 (normal)
• Lowest score 3 (deep coma)

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Diagnostic Tests

• Computed tomography(CT)
• Magnetic resonance imaging (MRI)
• Cerebral angiography
• Myelography
• Noninvasive carotid flow studies
• Transcranial doppler
• Electroencephalography (EEG)
• Electromyography (EMG)
• Lumbar puncture and analysis of cerebrospinal
  fluid