Cognitive and Perceptual
Disorders
Sarah Williams BSN, RN
BHSLR
Med Surge
Central Nervous System
Brain
z Spinal Cord
z Major functional divisions
*Higher-level brain
*Lower brain level
*Bony encasement
z
Brain: Cerebrum
z
z
Divided into cerebral hemispheres
Cerebral cortex (neocortex)
*Frontal lobes
*Parietal lobe
*Occipital lobe
*Temporal lobe
*Central lobe
1
Brain: Hippocampus
Part of the temporal lobe
z Memory function
-Short term memory
*Intermediate memory
*Long-term memory
z
Brain: Basal Ganglia
Consists of:
*Subcortical gray matter
*Internal capsule
z Controls motor activity
z
Brain: Composition
z
Diencephalon
z
Limbic system
*Thalamus and the hypothalamus
*Center of feelings and emotional expression
z
Brain stem
*Midbrain, pons, and medulla
z
Reticular formation
oblongota
*Skeletal motor functions
2
Brain: Cerebellum
Integrates sensory information related to
the position of body parts
z Coordinates skeletal muscle movement
and regulates muscle tension
z Nerve tracts
z
*Afferent
*Purposeful
*Efferent pathways
Spinal Cord
z
Protective and nutritional structures
*Cranium and vertebral column
*Meninges
*Cerebrospinal fluid and ventricular system
*Blood-brain barrier
*Arterial blood supply
*Venous supply
Cells of the Spinal Cord
z
Structure
*Neuroglia-glial cells
*Astrocytes
*Oligodendrocytes
*Microglia
*Ependymal
*Neurons-neurofibrils
*Unipolar
*Multipolar
*Bipolar
3
Spinal Cord
z
Impulse conduction
*Resting potential
*Nerve impulses
*Myelin
*Receptors
Peripheral Nervous System
z
Spinal nerves
*Doral (sensory) roots
*Ventral (motor) roots
z
Cranial nerves
*12 pairs motor/sensory
Autonomic Nervous System
z
Sympathetic nervous system
*Stress
*Short
z
Parasympathetic nervous system
*Conservation
*Long
4
Effects of Injury on the Nervous
System
Regeneration
z Effects of aging on the nervous system
z
Assessment of the Neurologic
System: History
z
Biographical and demographic data
*Personal profile
*Source of history
*Client’s mental status
z
z
Chief complaint
Symptom analysis
Neurologic System: History
z
Past health history
*Childhood and infectious diseases
*Major illnesses and hospitalizations
*Medications
*Growth and development
Family health history
Psychosocial history
z Review of systems
z
z
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Neurologic System: Physical
Examination
z
z
Vital signs
Mental status
*Level of consciousness
*Orientation
*Memory
*Mood and affect
*Intellectual performance
*Judgment and insight
*Language and communication
Neurologic System: Physical
Examination (cont.)
z
Head, neck, and back
*Inspection
*Palpation
*Percussion
*Auscultation
Neurologic System: Physical
Examination (cont.)
z
Cranial nerves
*Olfactory nerve (CNI): smell
*Optic nerve (CNII): vision
*Oculomotor (CNIII),trochlear (CNIV),
abducens (CNVI): eye control
*Trigeminal nerve (CNV): sensations of the
face, movement of the mouth
*Facial nerve (CNVII): facial muscles
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Neurologic System: Physical
Examination (cont.)
z
Cranial nerves
*Acoustic nerve (CNVIII): hearing
*Glossopharyngeal (CNIX), vagus (CNX)
nerves: palate, uvula
*Spinal accessory nerve (CNXI): muscles of
the shoulders and neck
*Hypoglossal nerve (CNXII): tongue
Neurologic System: Physical
Examination (cont.)
z
Motor system
*Muscle size
*Muscle strength
*Muscle tone
*Muscle coordination
*Gait and station
*Movement
*Motor testing of unconscious patients
Neurologic System: Physical
Examination (cont.)
z
Sensory function
*Superficial sensations
*Touch and pain
*Mechanical sensations
*Vibration
*Proprioception
z
Discrimination
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Neurologic System: Physical
Examination (cont.)
z
Normal reflexes
*Superficial (cutaneous) reflexes
*Abdominal reflex
*Plantar reflex
*Corneal reflex
*Pharyngeal reflex
*Cremasteric reflex
*Anal reflex
Neurologic System: Physical
Examination (cont.)
z
Normal reflexes
*Deep tendon reflexes
*Biceps jerk
*Triceps jerk
*Brachioradial jerk
*Knee jerk
*Ankle jerk
Neurologic System: Physical
Examination (cont.)
z
Abnormal reflexes
*Babinski’s reflex
*Rooting reflex
*Jaw reflex
*Sucking reflex
*Palm-chin reflex
*Clonus
*Snout reflex
z
*Glabella reflex
*Grasp reflex
*Chewing reflex
Grading reflex activity
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Neurologic System: Physical
Examination (cont.)
z
Autonomic nervous system
*Cannot be examined directly
*Clinical manifestations
*Increase/decrease heart rate
*Vasoconstriction/dilatation peripherally
*Bronchoconstriction/dilatation
*Increase/decrease peristalsis
*Pupil constriction/dilation
Neurologic System: Physical
Examination (cont.)
z
Functional assessment
*Note deficits and functional response
z
Clinical applications
Neurologic System: Diagnostic
Tests
z
Noninvasive tests of structure
*Skull and spinal x-ray studies
*Computed tomography
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Neurologic System: Diagnostic
Tests (cont.)
z
Noninvasive test of function
*Magnetic resonance spectroscopy
*Functional magnetic resonance imaging
*Positron emission tomography
*Electroencephalogram
*Evoked potential studies
*Neuropsychological testing
Neurologic System: Diagnostic
Tests (cont.)
z
Tests for vascular abnormalities
*Ophthalmodynamometry
*Doppler ultrasonography
*Doppler scanning
*Quantitative spectral phonoangiography
Neurologic System: Diagnostic
Tests (cont.)
z
Invasive test of structure
*Lumbar puncture
*Myelography
*Cerebral angiography
*Interventional angiography
*Digital venous angiography
*Cerebral perfusion studies
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Neurologic System: Diagnostic
Tests (cont.)
z
Invasive tests of function
*Caloric testing
*Peripheral nerve studies
*Muscle biopsy
*Cellular assessment
Management of Comatose
or Confused Clients
Definitions
z
Consciousness
z
Unconsciousness
z
Coma
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Disorders of Consciousness
Etiology and risk factors
z Pathophysiology
z Clinical manifestations
z Diagnostic findings
z Laboratory tests
z
*Oculocephalic reflex response
*Oculovestibular reflex response
Disorders of Consciousness
(cont.)
z
Medical management
*Determine level of involvement
*Reverse common causes of coma
*Prevent complications
Confusional States
z
Classifications of confusion
*Delirium
*Dementia
Etiology and risk factors
Clinical manifestations
z Medical management
z
z
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Management of Clients with
Cerebral Disorders
Seizure Disorders
z
Epilepsy
*Partial seizures with no loss of
consciousness
*Complex partial seizure
*Generalized seizures
z
Status epilepticus
Seizure Disorders: Epilepsy
z
Diagnostic tests
*Electroencephalogram (EEG)
*Computed tomography (CT)
*Skull x-ray
*Magnetic resonance imaging (MRI)
*Positron emission tomography (PET)
*Single photon emission computed
tomography (SPECT)
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Seizure Disorders: Epilepsy
(cont.)
z
Surgical management
*Cortical resection of the anterior temporal
lobe for complex partial seizures
*Cortical resection/corpus callosotomy
*Temporal lobectomy
*Hemispherectomy
*Vagal nerve stimulator implantation
Brain Tumors
Space-occupying lesions
z Increased intracranial pressure
z Intracranial tumors
z Glial tumors
z Oligodendrogliomas
z Pituitary tumors
z Ependymomas
z
Tumors of Supporting Structures
z
Meningiomas
z
Acoustic neuromas
z
Metastatic brain tumors
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Hemorrhagic Cerebrovascular
Disorders
z
Subarachnoid hemorrhage
*Intracranial aneurysm
*Arteriovenous malformation
z
Intracerebral hemorrhage
Infections
Bacterial meningitis
Bacterial toxins
z Brain abscess
z Viral infections
z Viral meningitis
z Viral encephalitis
z Fungal infections
z Toxoplasmosis
z
z
Headaches: Classifications
Tension headache
Cluster headache
z Migraine headache
z Lumbar puncture headache
z Postconcussion headache and syndrome
z
z
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Management of Clients with
Stroke
Stroke
z
Ischemic
*Caused by thrombotic or embolic blockage of
blood flow to the brain
z
Hemorrhagic
*Caused by bleeding into the brain tissue or
the subarachnoid space
Risk Factors: Stroke
z
Hypertension
z
Cardiovascular disease
z
Diabetes
z
Cigarette smoking
z
Excessive alcohol
z
Obesity
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Clinical Manifestations: Stroke
Hemiparesis (weakness)
z Hemiplegia (paralysis)
z Loss of speech
z Headache
z Vertigo
z Epistaxis
z Retinal hemorrhage
z
Deficits Post Stroke
z
Hemiparesis
z
Hemiplegia
z
Aphasia
z
Dysarthria
z
Sensory deficits
*Weakness
*Paralysis
*Communication
*Articulation
Deficits Post Stroke (cont.)
z
Dysphagia
z
Apraxia
*Swallowing
*Motor patterns
Visual changes
z Depth perception homonymous
hemianopia
z
*Visual loss
z
Behavioral changes
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Transient Ischemic Attacks
(TIAs)
z
Etiology
*Thromboembolism
z
Pathophysiology
*Transient decrease in blood supply to a focal
area of the brain
z
Clinical manifestations
*Rapid onset of weakness, aphasia, and
visual field cuts
TIAs (cont.)
z
Medical management
*Prevent the progression
z
Surgical management
z
Nursing management
*Carotid endarterectomy
*Neurologic assessments
Management of Clients with
Peripheral Nervous System
Disorders
18
Lower Back Pain
z
Etiology
*Biomechanical origins
*Destructive origins
z
Back strain
*Acute injury
z
Disc herniation
*Ruptured disc
Lower Back Pain (cont.)
z
Lordosis
*Backward concavity in the lumbar spine
z
Spondylolisthesis
z
Spondylolysis
*Forward stripping of one vertebra
*Structural defect in the neural arch of the
spine
Lower Back Pain (cont.)
z
Spinal stenosis
*Ligamentous infolding and hypertrophy of the
bone
*Sciatica: lumbar disc impinges on the sciatic
nerve
*Pain begins in the buttocks and extends
down the back of the thigh and leg
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Lower Back Pain (cont.)
z
Diagnostic findings
*Magnetic resonance imaging (MRI)
*Myelography
*Computed tomography (CT)
z
Medical management
*Goal: reduce pain and spasms
*Improve mobility and repair problem
Lower Back Pain (cont.)
z
Surgical management
*Chemonucleolysis
*Percutaneous discectomy
*Microdiscectomy
*Decompressive laminectomy
*Spinal fusion or arthrodesis
*Spinal fusion with instrumentation
Cervical Disc Disorders
z
z
Discs entrapped in cervical spine
Medical management
*Nonsteroidal anti-inflammatory drugs
(NSAIDs)
*Collar
*Muscle stretching
z
Surgical management
*Cervical fusion
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Post-Polio Syndrome
Syndrome occurs more than 30 years after
polio, which caused paralysis from
destruction of motor cells in the spinal cord
and brain stem
z Clinical manifestations
z
*Fatigue, weakness, temperature intolerance,
emotional distress, dysphagia
z
Treatment
*Pyridostigmine (Mestinon)
Spinal Tumors
Neurofibromas and meningiomas
z Clinical manifestations
z
*Vary according to location
z
Outcome management
*Surgery: if compression of the cord is evident
*Radiation
Vascular Spinal Cord Lesions
z
Myelomalacia
*Softening of the spinal cord from spinal cord
occlusion
z
Hematomyelia
*Hemorrhage into the spinal cord
z
Neurosyphilis
*Chronic or late stage of syphilis
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Disorders of the Cranial Nerves
z
Trigeminal neuralgia
z
Bell’s palsy
Disorders of the Peripheral
Nerves
Cumulative trauma disorder (CTD)
z Carpal tunnel syndrome (CTS)
z Ulnar nerve syndrome
z Tarsal tunnel syndrome
z Dupuytren’s contracture
z Ganglion
z
Management of Clients with
Degenerative Neurologic
Disorders
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Dementia
z
Alzheimer’s disease (AD)
*Preclinical Alzheimer’s disease
*Mild Alzheimer’s disease
*Moderate Alzheimer’s disease
*Severe Alzheimer’s disease
z
Multi-infarct dementia (MD)
Parkinson’s Disease
Classification
z Clinical manifestations
z Management of parkinsonian crisis
z Management of on/off response
z Surgical management
z
Creutzfeldt-Jakob Disease
z
Etiology
*Subacute central nervous system (CNS) disorder
that produces electroencephalogram (EEG) changes
and dementia
z
Clinical manifestations
*Vague psychiatric or behavioral changes
*Weight loss, anorexia, insomnia, malaise, and
dizziness
z
Outcome management
*Supportive care only: fatal disease
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Huntington’s Disease
Genetically transmitted degenerative
neurologic disease
z Clinical manifestations
z
*Abnormal movements
*Intellectual decline
*Emotional disturbance
z
Outcome management
*Supportive care: no known treatment
Multiple Sclerosis (MS)
Etiology: unknown
z Pathophysiology
z Clinical manifestations
z Diagnosis
z Treating acute relapses
z Treating exacerbations
z Symptomatic treatment
z
Guillain-Barré Syndrome
z
Etiology
*Inflammatory disease involving degeneration
of the myelin sheath of peripheral nerves
*Cause unknown
z
Clinical manifestations
*Ascending weakness
*Initial, plateau, recovery phase
z
Outcome management
*Supportive care
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Myasthenia Gravis
Etiology
z Clinical manifestations
z Diagnostic findings
z Myasthenic syndrome (Eaton-Lambert
syndrome)
z
Amyotrophic Lateral Sclerosis
(ALS)
Lou Gehrig’s disease
z Clinical manifestations
z
*Degeneration of lower and upper motor
neuron symptoms
*Relentlessly progressive
z
Outcome management
*Supportive care
Management of Clients With
Neurologic Trauma
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Increased Intracranial Pressure
Etiology
z Risk factors
z Pathophysiology
z Clinical manifestations
z
*Related to the location and cause of the
increased pressure
Herniation Syndromes
Transcalvarial: open head injury
z Central transtentorial: injury in cerebral
cortex
z Lateral transtentorial: displacement in
temporal lobe
z Cingulate: frontal lobes
z Infratentorial: cerebellar herniation
z
Traumatic Brain Injury
Mechanisms of injury
Primary injuries
z Diffuse axonal injury: involves entire brain
z Focal injuries
z Clinical manifestations
z Medical management
z Surgical management
z
z
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Spinal Cord Injury
Etiology
z Pathophysiology
z Clinical manifestation
z Syndromes causing partial paralysis
z Diagnosis
z Initial medical care
z Surgical management
z
Spinal Cord Injury
z
Rehabilitation
*Establish functional goals
*Promote mobility
*Reduce spasticity
*Improve bladder and bowel control
*Prevent pressure ulcers
*Reduce respiratory dysfunction
*Promote expression of sexuality
*Control pain
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