NEURO | Mr. Mike Chavez
NERVOUS SYSTEM
Subdivided into the CENTRAL and PERIPHERAL N.S.
CNS – center
PNS – extremities
CENTRAL – center of control the body (brain); all organs will not work if the brain shuts
Down
CRANIAL NERVES (communication of brain and muscles) → 12 pairs; SPINAL NERVES →
31 pairs
MUSCLES
Somatic (brain and consciousness)
•
Voluntary (consciously controlled), made up of Straited muscles like the musculoskeletal
•
Ex. walking
Autonomic
•
involuntary (reflexes); muscles directly controlled by the brain, made out of smooth muscles which are found in the visceral parts of the
body (internal organs)
•
Vital signs (Para and Sympa)
•
Ex. Digestion, Release of Insulin by Pancreas
Acetylcholine (and dopamine) – commonly a cause of most diseases
➢ brain: memory processing (best source: peanuts)
➢ earliest sign of low acetylcholine – memory loss (alzheimers) and poor in judgment (they are still doing their normal routine in the past)
➢ Abundantly produced in the morning
➢ 2nd Stage: Sundowning and Wandering – lumalabas ng bahay because they don’t recognize their environment
o Priority: safety—lock the main doors
o Medication: give upon the time of normal body production (acetylcholine – morning)
o HORMONE and NEUROTRANSMITTER → take meds in the morning OR at bedtime
MUSCLE → “MOTOR TRANSMISSION” – descending – contraction of muscles
➢ Ex: No acetylcholine impulse to the muscle → weakness = MG (severe muscle weakness)
CEREBRUM – consciousness (combination of the functions of the lobes of the brains) = collective function
a. Frontal – thinking and reasoning (analysis and speech or expression); motor
o [APHASIA] Expressive / BROCA’S – alternative communication (Ex. paper and pen for response)
o Behavior and Personality → In cases of CVA – changes in behavior / personality (if frontal lobe was affected)
*Cerebrum as a whole is voluntary (controlled)
b.
Temporal – hearing and memory; responsible for comprehension (to understand is to listen)
o [APHASIA] Receptive / Wernicke’s – use simple sentences and speak slowly
c.
Occipital – seeing (the future); visualization (brain produces a lot of hormones to achieve the visual); induces “motivation of energy”
d.
Parietal – tactile sensation (sense of touch); send messages to brain upon the touch → ascending
o The parietal lobe feels the pain
o If parietal lobe is damaged, check the temperature of everything (avoid giving warm compress, etc.)
1
NEURO | Mr. Mike Chavez
o
Paresthesia
CEREBELLUM → balance and coordination
➢ Control to protect during falls
➢ Walking: left foot and right hand forward (reciprocal walking)
➢ Cane: cane is held on the unaffected side always
➢ Priority: Safety
BRAIN STEM – respiratory reflex center of the brain
a. Midbrain – auditory and visual reflexes; incontrollable and involuntary
▪
Ex. LSS
▪
Visual even at night – fed to the midbrain of such visual from everyday exposure
b. Pons – patterns of breathing
▪
Rapid, slow, deep, shallow, apnea
▪
Rapid deep breathing → with chest movement = Hyperventilation (Too much O2 is inhaled because CO2 accumulated is needed
to be excreted)
o Respi alkalosis – too much O2
o Respi acidosis – too much CO2
▪
O2 is alkaline and CO2 is acidic
▪
Normally, when a person ran for 1km and suddenly stopped to catch their breath = hyperventilate
▪
A person sitting normally who did not do anything to be fatigued is hyperventilating = RESPI ALKALOSIS
o Too much O2 ingested
o Paper bag—balance the CO2 and O2 by re-ingesting CO2
▪
A person is a shallow breather
o Too much CO2 is retained
o RESPI ACIDOSIS
▪
Mgmt: Give O2
c. Medulla Oblongata – Responsible for the HR, RR, vomiting, coughing and sneezing
HYDROGEN – Inc = Acidic
pH – Inc = Alkaline
Which is more important? Brain stem or Cerebrum → BRAIN STEM (vital functions > thinking)
After a seizure attack, what is your priority? Turn your patient to side or reorient: SIDE → airway
FORAMEN MAGNUM
Skull covers the brain; foramen magnum is beneath the skull (Brain injuries are more fatal than spinal cord injuries)
Injuries in Vehicular Accidents – brain, cervical and lumbar
Pag na-damage ang lumbar, sira din ang cervical
Lumbar—catheter is yes, oxygen is no, patient can speak, patient wil have no coma, pt is
not confused, pt needs wheelchair
Cervical—catheter is yes, oxygen yes, pt can’t walk, pt can still speak
Brain—coma, no orientation
Paraplegia – paralyzed both legs
2
NEURO | Mr. Mike Chavez
Manifestations in most Diseases → Diagnosis through checking for a pt’s ICP
Possible causes of Increased ICP
(1) Tumor – abnormal tissue → compression
(2) Encephalitis – inflammation of brain
(3) Meningitis – inflammation of CSF
▪
Meninges – fluid portion; for the skull and brain to prevent friction rub
o Sub-arachnoid Spaces
▪
Within the ventricles
•
CSF → high in glucose (50-75 mg/dL)
o To nourish the brain and spinal
cord
•
Arterial and Venous Blood
▪
Lumbar Puncture
*Basilar Skull Fracture → nabasag yung base ng skull; nasal discharge is checked if there is glucose present within the fluid discharge
MD order: prophylactic, antibiotic
Break – bacterial growth → through the meninges = infection
*Rhinorrhea → may have a mix of CSF; blood has glucose in nature that is why it is not tested for presence of glucose
HALO – secretion → 4x4 sterile gauze –dry—if the blood remained red when dried = normal
If the blood has a yellowish ring when dried = presence of CSF = MENINGITIS = Refer
MD: antibiotic
*Na are small molecules that can penetrate through the skin = maalat ang body fluids secreted like sweat or tears
Choroid plexus in the brain produces glucose everyday (500 mL) → fed to the brain – circulated through the heart – excreted through the urine
Malformation of the brain → blockage of the ventricles (few CSF can pass); abnormal accumulation of CSF
o Hydrocephalus NON-COMMUNICATING
▪
VP Shunt → redirect CSF flow to peritoneal cavity
Accumulation of water → Cerebral Edema (Mgmt: Diuretics)
Cerebral swelling → Inflammation (Mgmt: Steroids)
~~All of these conditions ^^ are slowly developing~~
~~Emergency Cases: PRIORITY~
HPN – answer related to stroke;
there is no stroke that has low BP – shock
2 Types of Stroke
Ischemic – decreased perfusion (oxygen and blood supply)
Thrombo-embolic – stationary clot is thrombus | travelling clot is embolus
o Brain infarction – death of brain
o If the clot travelled to the brain and obstructed the right brain → paralysis is on the left
o Tetraplegia – all four extremities
o Hemiplegia – everything on the certain side is paralyzed
Mgmt: let the pt exercise/walk
It is possible that a clot may block both the right and left side
How to determine if the injury is cervical or brain: Assess LOC (If pt answered: cervical only)
Speech = cerebrum = consciousness (brain)
Children: Has more collagen in the blood vessels – high bp – dilate
Hemorrhagic – internal bleeding
Ruptured aneurysm – outpouching of the aneurysm
o Increased BP → outpouching
o Therefore hemorrhagic is more fatal than ischemic
o Usually arterial bleeding
Arterial – tourniquet
Venous – direct pressure
3
NEURO | Mr. Mike Chavez
IMPACT and HEMATOMA – hematoma is bleeding outside the blood vessels; pooling of blood under the skin
❖ Subdural H. – Veins
❖ Epidural H. – Arteries
•
Fatal
•
Cannot tourniquet
Earliest sign of Increased ICP – ALOC
Earliest sign of Altered Level of Consciousness – disorientation
Late sign – DLOC (decreased)
“Restlessness” = anxiety (di mapakali, tumataas CO2 sa brain)
•
Earliest sign of hypoxia
“Confusion” – decreased comprehension
•
Answers differently from the question / stimulus
“Disorientation” – sense of direction loss
•
First to be disoriented at: TIME (Number and intimate; not repetitive)
•
Next: PLACE (highly modifiable in a certain time)
•
PERSON (modifiable but still recognizable in a way)
ALOC / DLOC / Coma = Damage is up yet to the Cerebrum
ALOC – Cushing’s Triad = Brain Stem → more dangerous
DLOC (Lethargic) → if Downers are given = COMA
Seizures → may be given Downers (depending on the situation) but NO stimulants, dim light, quiet environment, near the nurses station (if needs
close monitoring), far from the nurses station (if stable or for discharge)
•
If admitted → acute or chronic type of seizures
Increased ICP – from hematoma – naiipit ang brain stem = Cushing’s Triad
Observe progress of disease; cannot be put in MRI for 24hrs
**Widened pulse pressure (Systolic minus Diastolic) + Hyper brady brady =
INCREASED ICP
**Hyper brady brady + normal ICP = HYPERTENSION
NORMAL PP: 30-40 mmHg
Mannitol cannot cure a PP of higher than 40mmHg
Ex. Pts BP is 190/110 (MD order is to give Mannitol – clarify to the MD
because PP is high – withhold medication)
BUT if given Mannitol → Continue to monitor V/S and I&O
Cushing’s Triad – Systolic Hypertension (There is widening of pulse pressure because systolic BP Is higher)
MB: Midbrain
MO: Medulla Oblongata
4
NEURO | Mr. Mike Chavez
Compress pons → Cheyne Stroke Respiration
•
hyperventilation – hypoventilation -- with periods of apnea
Compressed Med Ob → severe cerebral compression (lalabas ang brain stem sa skull to the foramen magnum)
•
projectile vomiting (3 to 4 ft) = death
•
why not HR? → not easily measurable by mere observation
Lumbar puncture is C/I = brain will be decompressed
Increased ICP is assessed before prescribing or ordering for anything
BSF if the discharge from the nose has blood + CSF
5