Intracranial Regulation

Syncope

sudden loss of strength, a temporary loss of consciousness (a faint) due to lack of cerebral blood flow (e.g., low BP)

The Romberg Test Normal findings document as negative Romberg test

Ask the person to stand up with feet together and arms at the sides. Once in a stable position, ask the person to close the eyes and to hold the position. Wait about 20 seconds. Normally, a person can maintain posture and balance even with the visual orienting information blocked, although slight swaying may occur. (Stand close to catch the person in case he or she falls.) Ask the person to perform a shallow knee bend

Cranial Nerves III, IV, and VI—Oculomotor, Trochlear, and Abducens Nerves

Palpebral fissures are usually equal in width or nearly so. Check pupils for size, regularity, equality, direct and consensual light reaction, and accommodation Assess extraocular movements by the cardinal positions of gaze

Neurological assessment

Perform screening neurological examination on well person with no significant findings from history Perform complete neurologic examination on person with neurological concerns Perform neurologic recheck examination on persons with demonstrated neurological deficits who require periodic assessment

*****

Score for mini mental state examination is 28 Maximum score is 30 Below 24 is impairment

Mental status assessment

Screen for: Anxiety disorders Suicide thoughts Depression

Cranial Nerve VIII—Acoustic (Vestibulocochlear) Nerve

Test hearing acuity by the ability to hear normal conversation and by the whispered voice test

Paresis

partial or incomplete paralysis.

8. How do you assess mental status in infants and children?

Emotional and cognitive functioning mature progressively from simple reflex behavior into complex logical and abstract thought. It is difficult to separate and trace the development of just one aspect of mental status. All aspects are interdependent. Consciousness gradually develops along with language so that by 18 to 24 months, the child learns that he or she is separate from objects in the environment and has words to express this. We also can trace language development: from the differentiated crying at 4 weeks, the cooing at 6 weeks, through one-word sentences at 1 year to multi-word sentences at 2 years. Yet the concept of language as a social tool of communication occurs around 4 to 5 years of age, coincident with the child's readiness to play cooperatively with other children. Attention gradually increases in span through preschool years so that by school age, most children are able to sit and concentrate on their work for a period of time. around age 7 years, thinking becomes more logical and systematic and the child is able to reason and understand. Abstract thinking, the ability to consider a hypothetical situation, usually develops between ages 12 and 15 years, although a few adolescents never achieve it.

11. What are the three areas of assessment on the Glasgow Coma Scale?

A Glasgow coma scale is the most widely used scoring system that determines the level of consciousness of an individual with a suspected or confirmed brain injury. Three areas of assessment -eye opening responses -motor responses -verbal responses

Mental status

A persons emotional and cognitive functioning Mental status strike a balance between good and bad days

Who is at risk for problems with ICR?

All populations are potentially at risk for problems with ICR. ICR problems related to degenerative pathology have a higher incidence in the elderly population. Injury-related ICR problems are more commonly seen in the adolescent and young adult age groups. The leading causes of TBI are falls and motor vehicle accidents.3 Falls are more of an issue with the very young and elderly populations; and because of risk-taking behavior, motor vehicle accidents are more prevalent in the young adult population. Personal risk factors are dependent on the cause of injury or pathology. For example, the risk factors for stroke include age, hypertension, diabetes, smoking, obesity, and cardiovascular disease. Some of the degenerative pathologic conditions have a strong genetic component, and put certain individuals at higher risk. Small children: due to increased falls

1. Discuss the development of the neurological system in infants.

Always think of development Always think about play: how they play: gait fine motor skills Issue will be found when they don't meet a developmental milestone

Reasons for doing mental status assessment

Anxiety disorders Aphasia Brain lesions, trauma, tumor, cerebrovascukar accident or strike Behavioral changes

Discuss "A, B, C, T".

Appearances Behaviors Cognition Thought process

What are the age related changes in mental status?

Children follow same ABCT guidelines take in developmental milestones Denver 2 test Kids older than 6 use a behavioral checklist: fill out along with their parents Adolescents follow adult guidelines

Cranial Nerve XI—Spinal Accessory Nerve

Examine the sternomastoid and trapezius muscles for equal size. Check equal strength by asking the person to rotate the head forcibly against resistance applied to the side of the chin. Then ask the person to shrug the shoulders against resistance. These movements should feel equally strong on both sides.

Canal nerve 1- olfactory nerve: smell

First, assess patency by occluding one nostril at a time and asking the person to sniff. Then, with the person's eyes closed, occlude one nostril and present an aromatic substance. Use familiar, conveniently obtainable, and non-noxious smells, such as coffee, toothpaste, orange, vanilla, soap, or peppermint.

7. List and describe three tests of cerebellar function.

Gait/tandem walking Romberg test Rapid alternating movement

How do we assess a patient for ICR problems?

History: Information in a history that provides data about intracranial function can relate to multiple systems. Asking pertinent questions will provide clues to the examiner of ICR problems and will help to focus the physical examination. Potential ICR areas on which to focus include the following: •Numbness, paralysis, tingling, neuralgia •Loss of consciousness, dizziness, fainting, confusion •Changes in recent or remote memory •Changes in vision, hearing, balance, gait •Speech problems (expressive and/or receptive) •Chewing/swallowing problems •Muscle weakness or loss of bowel or urinary control •Onset of unexplained tremors or other motion disturbances •Unexplained, severe headache •Vomiting •Symptom onset •History of head injury Physical Examination Findings Objective examination findings that convey neurologic status are found throughout a physical examination. Specific signs of dysfunction vary depending on the ICR problem. There are many age-related degenerative changes that occur in the central nervous system (CNS). When assessing an older adult, it is important to distinguish between these expected changes and changes potentially related to an ICR problem that could improve with appropriate treatment. Mental Status A complete mental status examination includes thorough assessment of the individual in the following categories: general description, emotional state, experiences, thinking, sensorium, and cognition. Depending on the patient's presenting condition, the nurse will decide which components of the exam are relevant. Mini mental status examination is an option A subtle change in cognitive and motor functioning occurs in the very old.12 When assessing an elderly patient, it is essential to determine the patient's baseline neurologic functioning in order to establish if there are significant changes.

9. What are some differences between the neurological assessment of the adult and infant? Pre-school and school-age child? Aging adult?

Infants and children: you will follow the same A-B-C-T guidelines as for the adult, with special consideration for developmental milestones.Denver II screening test gives you a chance to interact directly with the young child to assess mental status. The Denver II is designed to detect developmental delays in infants and preschoolers within four functions: gross motor, language, fine motor-adaptive, and personal-social skills. For mental status assessment, the Denver II helps identify young children who may be slow in development in behavioral, language, cognitive, and psychosocial areas. The test has 125 items arranged in chronologic order and displayed in groupings corresponding to recommended ages for health maintenance visits. School Aged Children: For school-age children, ages 7 to 11, who have grown beyond the age when developmental milestones are very useful, the "Behavioral Checklist" (Table 5-2) is an additional tool that can be given to the parent along with the history. It covers five major areas: mood, play, school, friends, and family relations. It is easy to administer and lasts about 5 minutes. Aging Adult: It is important to conduct even a brief examination of all older people admitted to the hospital. Confusion is common in aging people and is easily misdiagnosed. Up to 25% of older adults are hospitalized with acute delirium, and up to 56% develop acute delirium during their hospitalization.21a In comparison, about 10% of adults older than 65 years and 50% of adults older than 90 years have chronic dementia. Check sensory status before assessing any aspect of mental status. Vision and hearing changes due to aging may alter alertness and leave the person looking confused. When older people cannot hear your questions, they may test worse than they actually are. Older people with psychiatric mental illness test significantly better when wearing hearing aids.

Complete neurological assessment

Inspect and placate the motor system Muscle strength, size and tone Cerebellum function: gait- heel to toes walking- walk on toes then walk on heelsthe Romberg test: light sway "normal" negative Romberg, shallow knee bends, Rapid alternating Movements(RAM), finger to thumbtest: each hand, finger to finger: have them touch your finger with their finger, finger to nose test: each hand, heel to shin test Test resistance to muscles strength

Cranial Nerve XII—Hypoglossal Nerve

Inspect the tongue. No wasting or tremors should be present. Note the forward thrust in the midline as the person protrudes the tongue. Also ask the person to say "light, tight, dynamite," and note that lingual speech (sounds of letters l, t, d, n) is clear and distinct.

Primary Prevention

Leading a healthy lifestyle, which includes stopping smoking, maintaining a healthy weight, controlling blood pressure, and exercising, can decrease the risk of vascular disease impacting the cerebral arteries. Prevention/ reduction of brain injury •Reduce fatal traumatic brain injuries. •Reduce hospitalization for nonfatal traumatic brain injuries. •Reduce emergency department visits for nonfatal traumatic brain injuries.

10. List the components of the neurological recheck examination that are performed routinely on hospitalized persons being monitored for neurological deficit.

Level of consciousness Motor function Pupillary response Vital signs

Common tests and tools for assessment

Mental status testing Cranial nerve testing Glasgow coma scale National institute of health stroke scale

Cranial Nerve V—Trigeminal Nerve

Motor Function.Assess the muscles of mastication by palpating the temporal and masseter muscles as the person clenches the teeth (Fig. 23-9). Muscles should feel equally strong on both sides. Next, try to separate the jaws by pushing down on the chin; normally you cannot. Sensory Function.With the person's eyes closed, test light touch sensation by touching a cotton wisp to these designated areas on person's face: forehead, cheeks, and chin (Fig. 23-10). Ask the person to say "Now," whenever the touch is felt. This tests all three divisions of the nerve: (1) ophthalmic, (2) maxillary, and (3) mandibular.

Cranial Nerves IX and X—Glossopharyngeal and Vagus Nerves

Motor Function.Depress the tongue with a tongue blade, and note pharyngeal movement as the person says "ahhh" or yawns; the uvula and soft palate should rise in the midline, and the tonsillar pillars should move medially. Touch the posterior pharyngeal wall with a tongue blade, and note the gag reflex. Also note that the voice sounds smooth and not strained

Cranial Nerve VII—Facial Nerve

Motor Function.Note mobility and facial symmetry as the person responds to these requests: smile, frown, close eyes tightly (against your attempt to open them), lift eyebrows, show teeth, and puff cheeks. Then, press the person's puffed cheeks in, and note that the air should escape equally from both sides.

What are some diagnostic tests used to obtain information about a patient's neurological status?

Neuroimaging Studies: Imaging studies are essential to obtain in patients presenting with sudden neurologic deterioration, and may also be utilized with nonemergent conditions such as suspected brain tumor. noncontrast computed tomography (CT) magnetic resonance imaging (MRI) scan magnetic resonance angiography (MRA) positron emission tomography (PET) Skull Radiograph;a skull x-ray may be ordered to detect fractures, bone erosion, calcification, and/or abnormal vasculature Electroencephalogram (EEG);An EEG measures and records the brain's electrical activity through multiple electrodes placed on the scalp. Brain Biopsy;To determine the type and stage of a brain tumor, a biopsy is performed, usually during a surgical procedure. Preliminary histologic type can usually be determined quickly in the operating room; then the tumor is sent to pathology for complete analysis and final determination. Lumbar Puncture;The lumbar puncture (spinal tap) may be indicated when infection is suspected.

2. What changes do we see in the neurological system in the aging adult?

Older adult just needs more time: slower response time Steady loss of neurons in the brain Test sensory perception first: Four unrelated word testing older adults average 2 words which is okay

8. How do we assess the sensory system?

Pain Temperature Light touch: rub q tip across face legs arms: tell them to verbalized when they feel it: use paper clip for sharp and soft touch Stereognosis: put something in hand and have them recognize it and what hand graphesthesia: write letter in hand Kin esthetic:move finger up/ down( which finger which hand up or down)

Categories of impaired intracranial regulation

Perfusion: there must be a consistent flow of blood to the brain, interrupted or reduced blood flow to the brain impairs brain function and can lead to tissue death neurotransmission: there must be adequate transmission nerve impulses across the neuronal synapses by neurotransmitters for optimal brain function Pathology: brain tissue must be healthy for optimal function; diseases that affect brain tissue result in negative function.

What is the relationship between ICR and perfusion? ICR and neurotransmission? ICR and pathology?

Perfusion; For the brain to function optimally, there must be a consistent supply of blood, delivering oxygen and nutrients. Intracerebral perfusion can be disrupted in a number of different conditions such as internal blockage of a vessel, severe hypotension, or loss of vessel integrity attributable to damage or excessive external pressure on a vessel that exceeds perfusion pressure. Perfusion can also be disrupted as the result of an intracranial hemorrhage, such as a subdural hematoma or subarachnoid hemorrhage caused by a traumatic brain injury (TBI). A disruption of cerebral perfusion leads to a wide variety of ICR problems depending on the area of the brain that is affected and the length of time before perfusion is restored. Neurotransmission; Optimal functioning of the brain is dependent on the transmission of nerve impulses across neuronal synapses by neurotransmitters. Normal transmission requires fully functioning neurons, nerves, and neurotransmitters. Presynaptic neurons release neurotransmitters that travel to postsynaptic neurons. Neurotransmitters can be either excitatory or inhibitory Pathology; There are many pathologic states that disrupt intracranial functioning and regulation. Pathology of the brain can take many forms, such as brain tumors, degenerative diseases, and inflammatory conditions. The most common inflammatory conditions of the brain are abscesses, meningitis, and encephalitis. Although the etiology varies with each condition, the result is an inflammatory response that can result in disrupted cerebral function and regulation.

Pediatric differences

Reflexes disappear at various times during the first 5 months : babinski reflex Peripheral nerves not completely myelinated Neck muscles less developed: head lag normal up until 3 to 4 months After 4 months signs of neuralgic problem Brain of a term infant is 2/3 reds the weight of the adults brain( by age 6, weights 90%) Brain constitutes 12% of the newborns weight ( adult 2%)

3. How does culture and genetics affect a person's neurological system?

Stroke is the third most common cause of death in the United States There is geographic disparity; many states with high stroke mortality are concentrated in the U.S. southeast region, called the "stroke belt." This may occur because of the high proportion of people who live in this region who have two or more of the major modifiable risk factors for stroke (high BP, high cholesterol, diabetes, current smoking, physical inactivity, or obesity. African Americans also have high rates of stroke, and their risk factors are the following: higher prevalence of hypertension and diabetes than whites, and less likely to have BP controlled or diabetes treated than whites

Children

Subjective data for children: health history Pregnancy:prematurity, difficult birth, infections Family: genetic disorders Present illness: treatments at home, gait, falls, visual disturbance, change in behavior or mood, delayed growth and development

Common symptoms of stroke

Sudden weakness or numbness in face, arm, or legs Sudden confusion, trouble speaking or understanding

List 4 situations in which it is necessary to perform a complete mental status exam.

Systemic check of emotional and cognitive functioning Sequence of steps forms a hierarchy in which basic functions are assessed first Appearance: posture, body movements, dress, grooming and hygiene( keep in mind culture) Behavior: level of consciousness: first change a pat will exhibit, facial expressions, speech, mood and affect Cognition: orientation to (time, person and place), attention span, recent memory, remote memory, new learning- the 4 unrelated words test, judgment: what changes they will make after discharge Thought processes: logical, goal directed, thought content: what they say should be logical, perception: are they in the moment

Cranial Nerve II—Optic Nerve

Test visual acuity and test visual fields by confrontation Using the ophthalmoscope, examine the ocular fundus to determine the color, size, and shape of the optic disc

What does a Glasgow Coma Scale score of 15 mean? Of 8?

The Glasgow Coma Scale (GCS) was developed by Teasdale and Jennett in 197413 to give a standardized numeric score of the neurologic patient assessment. This is a widely used measurement tool that consists of three components: eye opening, verbal response, and motor response A coma is characterized by the total absence of arousal and awareness lasting greater than 1 hour. Generally, for adults a GCS score ≤8 is considered a coma; for children it is considered a GCS score ≤5. Clinical signs that correlate with poor prognosis after coma include the score for the motor component of GCS, the length of time in a coma, and signs of brainstem damage ****The higher the number the better the person is!!!!!!!!!! Eye opening Verbal response Motor response Scoring 13-15 mild 9-12 moderate 3-8 severe

Secondary Prevention (Screening)

There are no true screening tests available related to ICR. In the event of injury or the presence of clinical findings suggesting intracranial dysfunction, specific diagnostics tests are initiated to determine a cause.

dementia

a gradual progressive process, causing decreased cognitive function, even though the person is fully conscious and awake, and is not reversible. Alzheimer disease accounts for about two thirds of cases of dementia in older adults. Dementia is not part of normal aging.

Delirium

an acute confusional change or loss of consciousness and perceptual disturbance, may accompany acute illness (e.g., pneumonia, alcohol/drug intoxication), and is usually resolved when the underlying cause is treated.

What is the definition of Intracranial Regulation (ICR)?

mechanisms or conditions that impact intracranial processing and function.