these fibers conduct the sensation of position, vibration and finely localized touch

Position- without looking you know where your body parts are

vibration- feeling vibrating objects

finely localized touch- without looking you can idenify familar objects by touch

e.g patellar or knee jerk

five components are: an intect sensory nerve (afferent). A functional synapse in the cord, an intact motor nerve fiber (efferent). the neuromuscular junction, compentent muscle

arousal- eye opening

awareness- aware of self & the environment with the ability to focus and interact

level of consciousness

(fully conscious)

Level of consciousness

(confused)

Loss of consciousness

(lethargic)

Loss of consciousness

(obtunded

Loss of consciousness

(stuporous)

Loss of conscisousness

(comatose)

**test for eye opening, verbal response, motor response

15 point scale

good predictor of ST/LT morbidity and mortality

Limitations: not useful in alert patient with CVA, ventilated patient, sedated patient

15- normal

13-15- mild brain injury

9-12- moderate brain injury

3-8- server brain injury ( really worry about anything below 8)

equality

size, shape round, reactivity to light ( should get smaller)

Extraocular movement- look in all directions without moving there head

Disconjugate- one eye focus on an object and the other doesnt

CN III, IV, VI

always compare left to right or right to left

if asymmetry is abnormal

look at LOC and language

cranial nerves

motor

cerebellar

sensory

olfactory, smell, not tested rutinely, test ithe sense of smell in those who reoport loss of smell, head trauma

* with the persons eyes closed occlude one nostril and present an aromatic substance

Cranial nerve II

trigeminal; 3 branches sensation to the face, cornea and scalp, opens jaw against resistance

* motor :assess the muscles of mastication by palpating the temporal and masseter muscles as the person clenches the teeth

*sensory: with persons eyes closes test light touch sensation by touching a cotton wisp to designated areas on persons face

*corneal reflex: with person looking forward, bring a wisp of cotton in from the side and lightly touch the cornea, normally person will blink bilaterally

facial movement to face, taste

motor function: smile, frown, close eyes tightly, lift eyebrows show teeth, and puff cheeks

Abducens: moves eyes outward

usually want to assess III, IV and VI at once, check for pupil size, regularity, equality, direct and consensual light reaction, and accommodation

Nystagmus- back and forth oscullation of they eyes

acoustic: 2 branches, acoustic (hearing) and vestibular (balance)

whispered voice test, and by weber and rinne tuning fork test

glossopharyngeal: moves the pharynx (swallow, speech and gag)

Motor function: depress the tongue and note pharyngeal movement as person says ahh, uvula and soft palate should rise in the midline

vagus: voice quality

usually test gag, swallow and speech together IX, X, XII

Spinal accessory: turns head and elevates shoulder

examine the ternomastoid and trapezius muscles for equal size, check equal strength by having person push up on shoulders while you push down

0= absent

1+= hypoactive

2+= normal

3+= hyperactive

4+= hyperactive with jerking

verbal- simple and direct statements no visual or tactile stimuli

noxious (painful)- when no response to verbal stimuli acceptable methods: neail bed pressure, trapezius pinch

5/5 strong against resistance

4/5 weak against resistance

3/5 overcomes gravity, offers no resistance

2/5 cannot overcome gravity, moves with gravity eliminated

1/5 contracts muscle to stimulus muscle movement

assessing coordination, smooth movement, and position sense.

- test finger to nose, making sure patient has to fully extend arm (eyes open)

test for motor weakness

arm: hold arms out with palms up, eyes closed

motor drift: arm drifts downward

cerebellar drift: arm drifts back toward head or out to side

heel to shin test

person funs there heel on the opposite knee, normally a person can do this in a straight line down the shin

lock of coordintion, heel falls off shin, occurs with cerebellar disease

eliciting movements using central pain

trapezius pinch: deep pressure to trapezius muscle

supraorbital pressure: presure under supraorbital ridge

sternal pressure: knuckle pressure to sternum( do not rub)

peripheral pain: nail bed pressure may elict a spinal cord reflex which can be reproduced in a brain bead patient

• observe brathing pattern, position in bed and movement of extremities prior to stimulating patient
• use the least amount of stimulus
• first voice or lound clap, shake than pain
• assess pupil size and reaction
• stimulate eyelashes
• test corneal reflex by lightly touching cornea wih wisp of cotton
• assess gag by touching each side of pharynx

movement: observe for purposeful or non purposeful movement

tone: life arm 12-15 inches off bed and drop a rapid drop signifies coma and a slow drops signifies consciousness

this invovles artery access, than a contrast medium is injected to visualize cerebral circulation

used to detect traumatic injuries, vascular occulusions, tumors

nursing considerations: prior to procedure--maintain NPO, assess allergies to iodine, shellfish or IV dye

Lumbar puncture (spinal tap)

a needle is inserted into the subarachnoid space between the third and fifth lumbar vertebrae

used to obtain CSF measure CSF fluid or pressure

• dont do this on someone that is expected to have high ICF
• nursing considerations- post procedure- activity as prescribedL often bed rest with lying flat

cerebrospinal fluid (CSF)

normal finding

pH 7.35-7.45

specific gravity-1.007

appearance- clear, colorless, odorless

minimal number of WBCs and no RBC

psitive protein and glucose

allows for visualization of the verteral clumn, intervertebral disks, spinal nerve roots and blood vessels.

requires a lmbar puncture to inject into the subarachnoid space

considerations: maintain the head of bed elevated 15-30 degrees, encourage fluids

Electroencephalogram (EEG)

records the electrical activity of the brain through a series of electrodes on the scalp

used to diagnose and evaluate seizures disorders, identify tumors, brain absecesses or infection

blood (10%)

cerebral spina fluid (10%)

brain tissue (80%)

normal ICP less than or equal too 10 mmHg

head of bed elevated to 30 degrees

avoid extreme neck angulation and hip flexion

provide rest periods

reduce noxious environment stimuli

Monro- Kellie hyprothesis

this hypothesis says that increase in one intracranial component must be compensated by a decrease in one or more of the other components

the body has a limited ability to compensate in response to increased in ICP:

displacing CSF

increasing absorption of CSF

decreasing cerebral blood volume

this represents the pressure gradient driving cerebral blood flow and hence oxygen and metabolite delivery:

CPP=MAP-ICP

CPP normal limits- 80-100mmHg

CPP 80 is needed to ensure adequate blood supply

less than 30  will result in irreversible neurologic damage

CPP is maintained by either increasing MAP or decreasing ICP

Stages of increased ICP

              Stage 1 (full compensatory)

• alert and orientated 
• history of head injury
• vital signs/pupillary responsese normal
• may complain of headache

stage 2 (partial compensatory)

• mental status changes 
• confusion and restlessness
• decrease levle of consciousness

abnormal response is pucker lips

method of testing is gently percus oral region

indication: frontal lobe disease--alzheimers, amyotrophic sclerosis

abnormal response: sucking movement of lips, tongue, jaw, swallowing

method of testing: toch oral region

indication: same as for snout, alzheimers, amyotrophic sclerosis

abnormal response: uncontolled forced grasping

method of testing: touch palm with your finger

indication: when unilateral, frontal lobe lesion on contralteral side, when bilateral diffuse bifrontal lobe disease