Concepts of Neurologic Dysfunction

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Ohio State University Nursing 385.03

Consciousness is a state of awareness of ______ and the ______.

oneself, environment

What are the components of consciousness?

arousal, content of thought

Arousal is a state of ______ which is mediated by ______.

awakeness, RAS

Content of thought it mediated by all three basic core networks: ______, ______/______, and ______.

attention, memory/language, affective

What guides content of thought?

executive attention network

A loss of ______ function yields a vegetative state, which is a crude ______ ______.

cerebral, waking state

The crude waking state that is a vegetative state is maintained by ______ and the ______ ______.

RAS, brain stem

Alterations in arousal can be either ______, ______, or ______.

structural, metabolic, psychogenic

Structural alterations in arousal are divided by what?

they location above or below the tentorial plate (infra-tentorial vs. supra-tentorial)

The tentorial plate is a fold of the ______ ______ which separates the ______ from the ______ and often often encloses a process or plate of the skull called the ______ ______.

dura mater, cerebellum, cerebrum, bony tentorium

What sorts of things can cause metabolic alterations in arousal?

hypoxia, electrolyte imbalance, drugs, toxins, etc

Changes in arousal produced that are supratentorial can be produced by ______ dysfunction or ______ dysfunction.

diffuse, localized

Diffuse dysfunction that is supratentorial can be a disease process, such as ______, or disorders outside the brain but inside the cranial vault such as...(2)

encephalitis, neoplasms or closed head trauma with subdural bleeding

Localized dysfunction is often caused by a ______. Disorders in brain substance, such as ______ or ______, function as masses.

mass. infarcts or emboli

Localized supratentorial dysfunction can can cause impingement in what two ways?

either by impinging on deep structures directly OR impingement is secondary to herniation

Changes in arousal that are infratentorial are caused by either direct destruction of ______ and ______ or the entire ______ ______, or caused by direct ______ or indirect ______ of ______ supply.

RAS, pathways, brain stem, invasion, impairment, blood

Where do strokes typically occur in the brain?

in the cerebrum

What are the five types of clinical manifestations of altered arousal?

level of consciousness, pattern of breathing, pupillary changes, oculomotor responses, motor responses

What is the highest level of consciousness?

alert to self, others, place and time

What is the most critical index of neuro function?

level of consciousness

An individual may have ______ breathing patterns or ______ ______ breathing patterns.

hemispheric, brain stem

When looking at pattern of breathing, evaluate ______, ______ and ______.

rate, rhythm or pattern

What is "oculomotor responses" referring to?

how they eyes move

When evaluating motor responses, you are looking at their ______.

limbs

What are the three types of hemispheric breathing patterns?

normal, post-hyperventilation apnea, Cheynes-Stokes respirations

Normal breathing is not associated with an injury to the CNS. A person with normal breathing may ______ if needed to lower ______, but otherwise their breathing is ______ with decreased ______.

hyperventilate, PaCO2, regular, depth

Post-hyperventialation apnea is associated with...

diffuse bilateral metabolic or structural cerebrum disease

In post-hyperventilation apnea, a person ______ to lower ______ to normal. Then once it's normal, respirations ______. Rhythmic breathing will resume when ______ comes back up.

hyperventilates, PaCO2, stop, PaCO2

Cheynes-Stokes respirations are associated with ______ dysfunction in ______ cerebral or ______ structures.

bilateral, deep, diencephalic

Cheynes-Stokes respirations have a ______ rate and depth which ______. This is followed by smooth ______ to the point of ______. The period of ______ lasts longer than the ______.

crescendo, peaks, decrescendo, apnea, hyperpnea, apnea

What is an example of how Cheynes-Stokes would be charted?

"Cheynes-Stokes with 20 seconds of apnea"

What are the five types of brain stem breathing patterns?

central neurogenic hyperventilation, apneusis, cluster breathing (aka Biot's breathing), ataxic breathing, agonal breathing (gasping breathing)

How does a person with central neurogenic hyperventilation breathe? What is it related to?

sustained, deep, rapid and regular hyperpnea. head trauma.

How would central neurogenic hyperventilation affect a person's labs

decrease PaCO2 and pH and increase PaO2

A person with apneustic breathing takes a ______ ______ at full ______. This is called a ______. It often alternates with a pause at the end of ______.

prolonged pause, full inspiration, cramp, expiration

Apneustic breathing is related to damage in the ______ in the brain stem, ______ (severe), ______ and ______.

pons, hypoglycemia, anoxia, meningitis

Cluster breathing is also called...

Biot's breathing

Cluster breathing is characterized by ______ breaths followed by ______ ______. It is related to dysfunction in the lower ______ and ______.

quick, irregular pauses, pons, brainstem

Ataxic breathing is completely ______ breathing which is often ______. The person will have random ______ and ______ breaths with irregular ______.

irregular, slow. shallow and deep, pauses

Ataxic breathing is related to dysfunction in the ______ or a ______.

medulla, CVA

Agonal breathing is also called...

gasping breathing

Agonal breathing is very ______, ______, ______, ______ breaths.

slow, deep, sighing, gasping

When is agonal breathing commonly seen?

in cardiac arrest where respirations may persist after the heart has stopped

Why does agonal breathing occur following cardiac arrest?

body's last attempt to save itself. the pulse stops, the brain initiates a couple more breathes which may be 20-30 seconds apart.

Why might pupillary changes occur with altered arousal?

brain stem areas that control arousal are near areas that control pupils

Pupil changes can indicate the level of...

brain stem dysfunction

What are the three types of pupil "classifications?"

fixed vs. reactive, dilated vs. pinpoint, brisk vs. sluggish reaction to light

What part of the brain is responsible for whether pupils are fixed or reactive?

midbrain

Dilated pupils indicate dysfunction in the ______, whereas pinpoint pupils indicate dysfunction in the ______.

midbrain, pons

What part of the brain is responsible for the pupillary reaction to light?

midbrain

Besides damage to the brain, drugs can also cause pupillary changes. What things can cause constriction? What things can cause dilation?

opioids and alcohol. atropine and amphetamines.

Oculomotor responses change depending on...

the level of brain dysfunction

People with a ______-induced coma (e.g. ______ or ______) usually retain oculomotor responses, even in the presence of...

metabolically, hypoxia, hypoglycemia, other signs of brain stem damage

People with ______-______ and ______ poisoning do not retain the ocular reflexes.

barbituate-hypnotic, phenytoin (Dilantin)

The oculocephalic reflex response is also called...

the Doll's Eyes Phenomenon

The oculocephalic reflex response evaluates brain stem function in patients who are ______ or ______.

unconscious or comatose

What is a normal oculocephalic reflex response?

both eyes turn to side opposite from head turn, still able to maintain focus

What is an abnormal oculocephalic reflex response?

eyes do not turn in synchrony

What is an absent oculocephalic reflex response? What may it indicate?

eyes follow the head turn. may indicate brain damage/brain death.

Motor responses help evaluate the level of...

brain dysfunction

Motor responses help determine the most severely damaged ______ and may indicate a loss of ______ ______.

side, cortical inhibition

What is the range of motor responses?

purposeful--inappropriate/generalized--not present

What three reflexes are often referred to collectively as "frontal release" signs?

the suck, snout and palmomental reflexes

The suck, snout and palmomental reflexes are often seen in disorders that affect the ______ ______, such as...

frontal lobes. dementias, metabolic encephalopathies, CHI, hydrocephalus

Reflex grasping is normal up to what age?

1 years old

What is reflex sucking?

sucking movements by the lips when they are stroked or touched

What is the snout reflex?

puckering or protrusion of the lips with percussion

In the palmomental reflex, a stimulus to the ______ area (palm, near the base of the thumb), of the hand causes a reflex ______.

thenar, contraction

What is rigidity also called?

paratonia

What are the two abnormal flex and extensor responses?

decorticate and decerebrate

The decorticate position is due to damage to ______ ______ whereas the decerebrate position is due to damage of the ______ ______ ______.

corticospinal tracts, upper brain stem

What is the decorticate position?

flexion and adduction of the UEs. external rotation, plantar flexion in the LEs.

What is the decerebrate position?

all 4 extremities in rigid extension, hyperpronation of forearms, plantar flexion in LEs

What is selective attention?

the ability to select from available, competing environmental and internal stimuli affected

What are two types of sensory inattentiveness?

extinction and neglect syndrome

What is extinction?

the ability to recognize sensory input from from dysfunctional side of the brain but ignores sensory input from the dysfunctional side when stimulated from both sides

Neglect syndrome is the name for the entire complex of denial or ______, loss of ______ of own body parts and ______.

dysfunction, recognition, extinction

What is selective attention deficit?

inability to focus attention

What are three types of dysmnesias?

retrogade amnesia, anterograde amnesia, executive attention deficits

Retrograde amnesia results in a loss of memory of events that occurred...

before a head injury

Retrograde amnesia results from damage to ______ areas in the ______ ______.

association areas in the cerebral cortex

Retrograde amnesia is also called ______ ______ or ______ memory.

domain specific, remote memory

Anterograde amnesia is the inability to...

form new memories

Anterograde amnesia results from damage to the ______ or ______ lobe.

hippocampus or temporal lobe

What disease process is anterograde amnesia seen in?

Alzheimer's

Anterograde amnesia is also called ______ ______ or ______ memory.

domain independent, recent memory

Executive attention deficits involve the inability to maintain ______ ______, ______ ______ or recognize when an ______ meets a ______.

sustained attention, set goals, object, goal

People with executive attention deficits are unable to remember...

instructions and info needed to guide behavior

Executive attention deficits result from ______ and ______ or indirect destruction due to ______. They can also result from the effects of ______ and ______.

ischemia, hypoxia, compression, toxins, chemicals

Executive attention deficits involve the ______, as well as the ______ and ______ networks which are essential to cognitive function.

midbrain, memory and language

Agnosia is a defect of ______ ______.

pattern recognition

Agnosia may affect the domains of ______, ______, or ______, but it usually only affects one domain.

tactile, visual, auditory

A person with agnosia is unable to recognize/identify objects due to injury to the ______ cortex.

sensory

What is an example of tactile agnosia?

patient closes eyes, put a key in their hand, unable to recognize it

prosopagnosia

inability to identify well-known faces

amusia

impaired music interpretation

aphasia vs. dysphagia

aphasia is a LOSS of comprehension/production of language, whereas dysphagia is IMPAIRMENT

What does dysphagia result from?

damage to part of the left cerebral hemisphere

Dysphagia types are classified ______, ______ or the character of ______.

anatomically, functionally, speech

What are the three types of dysphagias?

expressive, receptive, transcortical

Expressive dysphagia is primarily a deficit of ______. ______ ______ deficit may also be present but usually is relatively intact.

expression, verbal comprehension deficit

Expressive dysphagia is also called ______ dysphagia or ______ dysphagia.

Broca dysphagia, motor dysphagia

A person with receptive dysphagia can produce verbal language but it is ______. This is also called ______ or ______ dysphagia.

meaningless, Wernicke or sensory dysphagia

A person with transcortical dysphagia has an inability to ______. They may range from ______ and producing little speech to ______ with impaired ability for ______.

repeat. nonfluent, fluent, naming

ACS

acute confusional states

Acute confusional states can be secondary to ______ ______, ______ disorder, or ______ system disease.

drug intoxication, metabolic disorder, nervous system disease

The onset of an acute confusional state can be ______, or ______, but it is usually ______.

sudden, gradual, abrupt

AMS

acute mental status

Acute confusional states may be caused by disruption of the neural network in ______ and projections into the ______, ______ ______, ______ or ______ areas.

RAS, thalamus, basal ganglion, cortex, limbic areas

Acute confusional states may be seen as ______, because the person may have grossly altered interpretations of ______, possibly including ______. They may also be ______.

delirium, reality, hallucinations, incoherent

What is the function of the forebrain?

to put all of our thoughts together

AMS usually functions as a ______ diagnosis when we are unsure of what's going on with a patient.

temporary

Dementia is a ______ failure of ______ functions that is not caused by an impaired level of ______.

progressive, cerebral, consciousness

Dementia can occur due to...

degeneration, compression, atherosclerosis, and trauma

What are the two classifications of dementia?

cortical, subcortical

Dementia is not ______. The treatment of it seeks to maximize use of remaining ______ and______.

curable, capacities and functions

The symptoms of dementia begin ______. They include a loss of both ______ and ______ memory.

insidiously. recent and remote

What are the two types of Alzheimer's? Which is most common?

late onset familial Alzheimer dementia AND non-hereditary or sporadic late-onset AD (more common)

All theories of Alzheimer's include a ______ being affected.

protein

The theories of what causes Alzheimer's include a mutation for encoding ______ ______ protein, alteration in ______ ______ and loss of neurotransmitter stimulation of ______ ______, and ultimately ______.

amyloid precursor protein, apolipoprotein E, choline acetyltransferase, Ach

What is evident in the brain of a person with Alzheimer's?

neurofibrillary tangles

A person with Alzheimer's will have "______ ______," which are area of ______ which disrupt nerve-impulse transmission.

senile plaques, degeneration

What are the symptoms of Alzheimer's?

forgetfullness, emotional upset, disorientation, confusion, lack of concentration, decline in abstraction, problem solving and judgement

What is the usual treatment of Alzheimer's?

Aricept (donepezil)--Anti-Alzheimer, cholinesterase inhibitor, doesn't prevent progression

CBF

cerebral blood flow

CPP

cerebral perfusion pressure

What is CPP? What does it decrease in response to?

cerebral perfusion pressure. pressure needed to perfuse brain cells. decreases in response to IICP.

What does CBV stand for? It is the amount of blood in the _____ _____.

cerebral blood volume. intracranial vault.

Cerebral oxygenation is the _____ _____ in what vein?

oxygen saturation in the internal jugular vein

IICP leads to brain tissue _____.

hypoxia

What is normal intracranial pressure?

5 to 15 mm Hg

Increased intracranial pressure is caused by an increase in...

intracranial content

What are some examples of things that can cause IICP?

tumor growth, edema, excessive CSF, hemorrhage

How many stages of IICP are there? What follows them?

1-4. death

The stages of IICP are differentiated by _____ status, _____, _____, _____ and widening/narrowing _____ _____, _____ (rate and quality), and _____.

mental status, pupils, breathing, BP, pulse pressure, pulse, temperature

During what stages of IICP is the person compensating?

1 and 2

What symptoms/signs may a person with stage I of IICP experience?

awake, alert, pupils and breathing normal, systolic BP may be somewhat elevated, pulse pressure fine, pulse may normal to elevated

What symptoms of effective compensation may a person with stage I of IICP experience? (2) What is their purpose?

vasoconstriction and external compression of venous system. to make sure that CPP remains normal.

What symptoms may a person with stage II of IICP experience?

episodes of confusin, restless, lethargy

How are the pupils of a person with stage II IICP? How is their breathing?

pupils still equal and reactive, breathing still normal

Why would a person with stage II IICP have a systemic increase in BP?

to overcome the IICP

During what stage of IICP is a medical/surgical intervention best?

stage II

Stage III of IICP marks the start of _____.

decompensation

During stage III of IICP, the brain can no longer adjust to...

the increase in ICP.

In stage III of IICP, the person begins to have an inability to _____ _____. They progress into a deeper _____.

stay awake, deeper coma

In stage III of IICP, how are the pupils? How is breathing?

small and reactive, progressing slowing of response to light. breathing is normal but may begin to slow.

In stage III of IICP, the _____ _____ begins to widen due to an increase in _____ blood pressure.

pulse pressure, systolic

What happens to the pulse of a person with stage III of IICP?

pulse begins to slow and becomes full and bounding

What is the cushing reflex?

increase in BP and PP but a decrease in pulse

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