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Published on April 15, 2008

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NURSING OF ADULTS 111 Introduction to Neurological Nursing

NERVOUS SYSTEM CENTRAL NERVOUS SYSTEM BRAIN SPINAL CORD PERIPHERAL NERVOUS SYSTEM CRANIAL NERVES---12 pairs SPINAL NERVES---31 pairs 8 CERVICAL 12 THORACIC 5 LUMBAR 5 SACRAL 1 COCCYGEAL AUTONOMIC NS SYMPATHETIC PARASYMPATHETIC

CENTRAL NERVOUS SYSTEM

BRAIN

SPINAL CORD

PERIPHERAL NERVOUS SYSTEM

CRANIAL NERVES---12 pairs

SPINAL NERVES---31 pairs

8 CERVICAL

12 THORACIC

5 LUMBAR

5 SACRAL

1 COCCYGEAL

AUTONOMIC NS

SYMPATHETIC

PARASYMPATHETIC

CENTRAL NERVOUS SYSTEM 1 . Spinal cord (automatic motor responses—pathways for messages to and from the brain) 2. Lower brain (control of B.P., resp, equilibrium, muscular movements, primitive emotions) -basal ganglia, thalamus, hypothalamus, midbrain, pons, medulla & cerebellum 3. Higher brain (cortical function –memory, reasoning, speech, vision, hearing, sensation, abstraction & patterns of responses, ) cerebral cortex

1 . Spinal cord (automatic motor responses—pathways for messages to and from the brain)

2. Lower brain (control of B.P., resp, equilibrium, muscular movements, primitive emotions) -basal ganglia, thalamus, hypothalamus, midbrain, pons, medulla & cerebellum

3. Higher brain (cortical function –memory, reasoning, speech, vision, hearing, sensation, abstraction & patterns of responses, ) cerebral cortex

. 1 . Central Nervous System = Brain & Spinal Cord 2. Peripheral Nervous System = 12 Cranial & 31 Spinal Nerves 3. Autonomic Nervous System = Hypothalamus (part of CNS) Sympathetic Nervous System – important in emergency situations –”fight or flight” response--increase in heart rate, dilatation of bronchioles, dilatation of pupils, vasoconstriction of skin & skeletal muscles, slowing peristalsis, secretion of nor/epinephrine Parasympathetic nervous system – brings about responses assc. With restful activites--constriction of pupil, promotes digestion, slows heart rate

2. Peripheral Nervous System = 12 Cranial & 31 Spinal Nerves

3. Autonomic Nervous System = Hypothalamus (part of CNS)

Sympathetic Nervous System – important in emergency situations –”fight or flight” response--increase in heart rate, dilatation of bronchioles, dilatation of pupils, vasoconstriction of skin & skeletal muscles, slowing peristalsis, secretion of nor/epinephrine

Parasympathetic nervous system – brings about responses assc. With restful activites--constriction of pupil, promotes digestion, slows heart rate

The Brain Centre of our thought Interpreter of our external environment Origin of control over conscious (voluntary) and unconscious (involuntary) movement

Centre of our thought

Interpreter of our external environment

Origin of control over conscious (voluntary) and unconscious (involuntary) movement

FUNCIONAL AREAS OF THE CEREBRAL CORTEX Frontal Lobe Parietal Lobe Temporal Lobe Brain Stem Occipital Lobe Cerebellum Written speech Motor speech Auditory receiving area Auditory interpretation area Motor cortex Sensory area (pain, touch, etc.) Visual interpretation area Visual receiving area

Functions of the cerebral cortex: Frontal lobe – “personality” also contains the motor cortex – controls voluntary motor activity. Prefrontal areas controls Concentration Motivation Ability to formulate or select goals Ability to plan Ability to initiate or terminate actions Ability to self monitor Ability to use feedback

Frontal lobe – “personality” also contains the motor cortex – controls voluntary motor activity.

Prefrontal areas controls

Concentration

Motivation

Ability to formulate or select goals

Ability to plan

Ability to initiate or terminate actions

Ability to self monitor

Ability to use feedback

Cerebral Cortex (cont.) Parietal lobes – have primary receptive areas for tactile sensations i.e. temperature, touch, pressure. Also has association areas – spatial orientation and awareness of size & shape & body position (proprioception). Occipital lobe – visual receptive & association area. Visual memories are stored in this lobe – helps visually recognize & understand our environment.

Parietal lobes – have primary receptive areas for tactile sensations i.e. temperature, touch, pressure. Also has association areas – spatial orientation and awareness of size & shape & body position (proprioception).

Occipital lobe – visual receptive & association area. Visual memories are stored in this lobe – helps visually recognize & understand our environment.

Cerebral Cortex (cont) Temporal lobes – auditory receptive area & secondary auditory association area. Language memories are stored on the left side. On the right side all other sound memories that are not memories Animal sounds, train whistles, automobile horn etc. Damage to Wernicke’s area causes the inability to understand spoken or written language or recognize music.

Temporal lobes – auditory receptive area & secondary auditory association area. Language memories are stored on the left side. On the right side all other sound memories that are not memories

Animal sounds, train whistles, automobile horn etc.

Damage to Wernicke’s area causes the inability to understand spoken or written language or recognize music.

Cognitive Function Each area of the brain controls particular activities. Generally the outer and forward areas share more advanced function; the inner structures determine basic metabolic processes. Each side of the brain receives the sensory impressions and activates the muscles of the opposite side of the body .

Each area of the brain controls particular activities. Generally the outer and forward areas share more advanced function; the inner structures determine basic metabolic processes. Each side of the brain receives the sensory impressions and activates the muscles of the opposite side of the body .

WHAT PROTECTS THE BRAIN? SKULL 8 bones encase the brain protecting it (frontal, temporal, parietal, occipital) fuse in childhood in junctions called sutures. MENINGES Fibrous connective tissue covering the brain the spinal cord providing protection, support, and nourishment Dura Mater, Arachnoid, Pia Mater CSF Clear, colorless fluid 100-160 mls circulate b/w the subarachnoid spaces & the ventricles. Approx. 500 mls produced per day, most is reabsorbed by the bld. Consider pressure on the brain, if not reabsorbed. Cushions and Shock Absorber BLOOD-BRAIN BARRIER Blocks macromolecules and many compounds from dyes and medications from reaching the neurons. Helps keep a stable env. for neurons by regulating ion movement.

SKULL

8 bones encase the brain protecting it (frontal, temporal, parietal, occipital) fuse in childhood in junctions called sutures.

MENINGES

Fibrous connective tissue covering the brain the spinal cord providing protection, support, and nourishment

Dura Mater, Arachnoid, Pia Mater

CSF

Clear, colorless fluid 100-160 mls circulate b/w the subarachnoid spaces & the ventricles. Approx. 500 mls produced per day, most is reabsorbed by the bld. Consider pressure on the brain, if not reabsorbed.

Cushions and Shock Absorber

BLOOD-BRAIN BARRIER

Blocks macromolecules and many compounds from dyes and medications from reaching the neurons.

Helps keep a stable env. for neurons by regulating ion movement.

NEURONS Neurons (specialized cells), make complex connections with one another to send and receive messages in the brain and spinal cord. The brain and spinal cord is like a computer, the neurons are like the switches and circuitry that make it work.

Neurons (specialized cells), make complex connections with one another to send and receive messages in the brain and spinal cord.

The brain and spinal cord is like a computer, the neurons are like the switches and circuitry that make it work.

CEREBRAL CIRCULATION Receives 15% of cardiac output High metabolic demand and does not store nutrients – can be critical with diabetics (glucose) feel shaky, foggy, confused. Flows against gravity (arteries fill from below and veins drain from above) Cannot tolerate a decrease in blood flow b/c there is no collateral circulation.

Receives 15% of cardiac output

High metabolic demand and does not store nutrients – can be critical with diabetics (glucose) feel shaky, foggy, confused.

Flows against gravity (arteries fill from below and veins drain from above)

Cannot tolerate a decrease in blood flow b/c there is no collateral circulation.

Brainstem - The lower extension of the brain where it connects to the spinal cord. Neurological functions located in the brainstem include those necessary for survival (breathing, digestion, heart rate, blood pressure) and for arousal (being awake and alert). Most of the cranial nerves come from the brainstem . The brainstem is the pathway for all fiber tracts passing up and down from peripheral nerves and spinal cord to the highest parts of the brain.

Anatomy of the Autonomic Nervous System (Brunner 2000, p. 1618) What impact on body re SC injury?

EFFECTS ON AGING Loss of nerve cells therefore slower to receive and send messages Learning , memory and reasoning decline Memory loss for recent events Takes longer to process thoughts and put them into action No change in intelligence but it takes longer to learn Decreased ability to hear, see certain colors, decreased peripheral vision, sense of smell Reduced taste buds and sense of touch in fingers and toes

Loss of nerve cells therefore slower to receive and send messages

Learning , memory and reasoning decline

Memory loss for recent events

Takes longer to process thoughts and put them into action

No change in intelligence but it takes longer to learn

Decreased ability to hear, see certain colors, decreased peripheral vision, sense of smell

Reduced taste buds and sense of touch in fingers and toes

Cognitive and Perceptual Disorders Assessment of the Neurologic System

Assessment of the Neurologic System

Neurologic System: History Biographical and Demographic Data (is the data reliable) Current Health (what brought them to seek care) Past Health History Childhood & Infectious Diseases – meningitis, herpes Major Illnesses & Hospitalizations –diabetis, CVA, liver failure Medications – prescribed, OTC, herbal Growth and Development – duration of problem Family Health History- ALS, MD, Huntington’s Psychosocial History – personality changes, sleep patterns, stressors, exposure to chemicals, pesticide (Agent Orange)

Biographical and Demographic Data (is the data reliable)

Current Health (what brought them to seek care)

Past Health History

Childhood & Infectious Diseases – meningitis, herpes

Major Illnesses & Hospitalizations –diabetis, CVA, liver failure

Medications – prescribed, OTC, herbal

Growth and Development – duration of problem

Family Health History- ALS, MD, Huntington’s

Psychosocial History – personality changes, sleep patterns, stressors, exposure to chemicals, pesticide (Agent Orange)

Neurologic System: Physical Exam Cervical spinal cord injury can exhibit dec. B/P, P & T – (loss of sympathetic nervous system) Vital Signs – note changes Mental Status – note changes Level of Consciousness Orientation Memory – long & short term Mood and Affect- aggression & euphoria Intellectual Performance – knowledge/calculation Judgment and Insight – assess reasoning Language and Communication – fluent & appropriate

Cervical spinal cord injury can exhibit dec. B/P, P & T – (loss of sympathetic nervous system)

Vital Signs – note changes

Mental Status – note changes

Level of Consciousness

Orientation

Memory – long & short term

Mood and Affect- aggression & euphoria

Intellectual Performance – knowledge/calculation

Judgment and Insight – assess reasoning

Language and Communication – fluent & appropriate

Neurologic System: Physical Exam Head, Neck, and Back Inspection – raccoon’s eyes – basal skull fx (look for CSF from nares) Battle’s sign – middle basal skull fx – bruising over mastoid process (look for CSF from ears) Palpation Nodules, boggy skull, nuchal rigidity Percussion Gentle percussion – watch for pain response Auscultation Major neck vessels – turbulent - ? High risk for CVA

Head, Neck, and Back

Inspection –

raccoon’s eyes – basal skull fx (look for CSF from nares)

Battle’s sign – middle basal skull fx – bruising over mastoid process (look for CSF from ears)

Palpation

Nodules, boggy skull, nuchal rigidity

Percussion

Gentle percussion – watch for pain response

Auscultation

Major neck vessels – turbulent - ? High risk for CVA

Neurologic System: Physical Exam Cranial Nerves Olfactory Nerve (CNI): Smell Optic Nerve (CN II): Vision Oculomotor (CNIII),Trochlear (CNIV), Abdocens (CNVI): Eye control Trigeminal Nerve (CNV): Sensations of the face, movement of the mouth Facial Nerve (CNVII): Facial muscles Acoustic Nerve (CNVIII): Hearing Glossopharyngeal (CNIX), Vagus (CNX) Nerves: Palate, Uvula Spinal Accessory Nerve (CNXI): Muscles of the Shoulders and Neck Hypoglossal Nerve (CN XII): Tongue

Cranial Nerves

Olfactory Nerve (CNI): Smell

Optic Nerve (CN II): Vision

Oculomotor (CNIII),Trochlear (CNIV), Abdocens (CNVI): Eye control

Trigeminal Nerve (CNV): Sensations of the face, movement of the mouth

Facial Nerve (CNVII): Facial muscles

Acoustic Nerve (CNVIII): Hearing

Glossopharyngeal (CNIX), Vagus (CNX) Nerves: Palate, Uvula

Spinal Accessory Nerve (CNXI): Muscles of the Shoulders and Neck

Hypoglossal Nerve (CN XII): Tongue

Neurologic System: Physical Exam Motor System Muscle Size- symmetrical Muscle Strength - symmetrical Muscle Tone – rigid/flaccid/normal Muscle Coordination – repetitive movement Gait and Station- proprioception Movement – fine & gross motor Motor Testing of Unconscious Patients – to test response to pain – sternal rub, pressure on nail bed, orbit of the eye.

Motor System

Muscle Size- symmetrical

Muscle Strength - symmetrical

Muscle Tone – rigid/flaccid/normal

Muscle Coordination – repetitive movement

Gait and Station- proprioception

Movement – fine & gross motor

Motor Testing of Unconscious Patients – to test response to pain – sternal rub, pressure on nail bed, orbit of the eye.

Neurologic System: Physical Exam Sensory Function Superficial Sensations Touch and Pain Mechanical Sensations Vibration – tuning fork Proprioception Discrimination – stereognosis – distinguish objects, graphism – trace letters on palm of hand

Sensory Function

Superficial Sensations

Touch and Pain

Mechanical Sensations

Vibration – tuning fork

Proprioception

Discrimination – stereognosis – distinguish objects, graphism – trace letters on palm of hand

Neurologic System: Physical Exam Abnormal Reflexes Babinski’s Reflex Jaw Reflex Palm-Chin Reflex Clonus Snout Reflex Rooting Reflex Sucking Reflex Grasp Reflex Chewing Reflex

Abnormal Reflexes

Babinski’s Reflex

Jaw Reflex

Palm-Chin Reflex

Clonus

Snout Reflex

Rooting Reflex

Sucking Reflex

Grasp Reflex

Chewing Reflex

Posturing Abnormal flexion (decorticate) internal rotation of the arms & wrists Abnormal extension (decerebrate) extension & external rotation of arms & wrists – more serious than abnormal flexion - midbrain

Abnormal flexion (decorticate) internal rotation of the arms & wrists

Abnormal extension (decerebrate) extension & external rotation of arms & wrists – more serious than abnormal flexion - midbrain

Neurologic System: Physical Exam Normal Reflexes Superficial (cutaneous) Reflexes Abdominal Reflex Plantar Reflex Corneal Reflex Pharyngeal Reflex - gag Cremasteric Reflex Anal Reflex – check with MVA Deep Tendon Reflexes

Normal Reflexes

Superficial (cutaneous) Reflexes

Abdominal Reflex

Plantar Reflex

Corneal Reflex

Pharyngeal Reflex - gag

Cremasteric Reflex

Anal Reflex – check with MVA

Deep Tendon Reflexes

Neurologic System: Physical Exam Autonomic Nervous System Cannot be examined directly Clinical Manifestations Increase/Decrease Heart Rate Vasoconstriction/Dilatation Peripherally Bronchoconstriction/Dilatation Increase/Decrease Peristalsis Pupil Constriction/Dilatation

Autonomic Nervous System

Cannot be examined directly

Clinical Manifestations

Increase/Decrease Heart Rate

Vasoconstriction/Dilatation Peripherally

Bronchoconstriction/Dilatation

Increase/Decrease Peristalsis

Pupil Constriction/Dilatation

Neurologic System: Physical Exam Functional Assessment Clinical Applications Diagnostic Tests-Noninvasive Skull and Spinal X-Ray Studies Computed Tomography Magnetic Resonance Imaging Positron Emission Tomography

Functional Assessment

Clinical Applications

Diagnostic Tests-Noninvasive

Skull and Spinal X-Ray Studies

Computed Tomography

Magnetic Resonance Imaging

Positron Emission Tomography

Neurologic System: Diagnostic Tests Invasive Lumbar Puncture Myelography Cisternal Puncture Cerebral Angiography Cerebral Perfusion Studies

Invasive

Lumbar Puncture

Myelography

Cisternal Puncture

Cerebral Angiography

Cerebral Perfusion Studies

Neurologic System: Diagnostic Tests Noninvasive Tests of Function Electroencephalogram Evoked Potential Studies Neuropsychological Testing Invasive Tests of Function Caloric Testing Peripheral Nerve Studies Muscle Biopsy Cellular Assessment

Noninvasive Tests of Function

Electroencephalogram

Evoked Potential Studies

Neuropsychological Testing

Invasive Tests of Function

Caloric Testing

Peripheral Nerve Studies

Muscle Biopsy

Cellular Assessment

CONSCIOUSNESS … is a state of general awareness of oneself and environment. Consciousness has two components: 1. Arousal (wakefulness) : concerned with the person’s wakefulness (Controlled by Cerebral Cortex Function + Upper Brain Stem) 2. Content/cognition/awareness (cognitive + affective function or awareness of self): the sum of cerebral mental functions (Controlled by Cerebral Cortex Function).

… is a state of general awareness of oneself and environment.

Consciousness has two components:

1. Arousal (wakefulness) : concerned with the person’s wakefulness (Controlled by Cerebral Cortex Function + Upper Brain Stem)

2. Content/cognition/awareness (cognitive + affective function or awareness of self): the sum of cerebral mental functions (Controlled by Cerebral Cortex Function).

AROUSAL The mediator of arousal and sensory stimulation is the RETICULAR ACTIVATING SYSTEM (RAS). The RAS is located in the Brain Stem and contains projections between the Thalamus and the Cortex. A network of neurons in the RAS monitors ascending and descending stimuli. Nerve cells run through the medulla, pons, midbrain, thalamus, and hypothalamus. RAS maintains muscle tone, keeps the higher brain in a state of alert wakefulness, and filters incoming messages .

HOW UNCONSIOUSNESS OCCURS Disruption of the ascending reticular activating system (extending from the length of the brain stem into the thalamus) Disruption in the function of one or both cerebral hemispheres Metabolic depression of the brain (i.e.-----as with drug overdose)

Disruption of the ascending reticular activating system (extending from the length of the brain stem into the thalamus)

Disruption in the function of one or both cerebral hemispheres

Metabolic depression of the brain (i.e.-----as with drug overdose)

DISORDERS PRODUCING UNCONSCIOUSNESS Structural lesions in the brain placing pressure on the brain stem or other structures Brain tumors Head trauma Cerebral hemorrhage Metabolic disorders and diffuse lesions Hypoxia/Ischemia Liver, lung and kidney disorders Toxins, hypoglycemia, fever, infections, fluid/electrolyte imbalance, acid-base imbalance Psychogenic causes Catatonia and Hysteria

Structural lesions in the brain placing pressure on the brain stem or other structures

Brain tumors

Head trauma

Cerebral hemorrhage

Metabolic disorders and diffuse lesions

Hypoxia/Ischemia

Liver, lung and kidney disorders

Toxins, hypoglycemia, fever, infections, fluid/electrolyte imbalance, acid-base imbalance

Psychogenic causes

Catatonia and Hysteria

Why is it important to assess LOC? How do we do this?

Why is it important to assess LOC?

How do we do this?

Stages of decreasing LOC ALERT CONFUSION DISORIENTATION LETHARGY OBTUNDATION STUPOR COMA

ALERT

CONFUSION

DISORIENTATION

LETHARGY

OBTUNDATION

STUPOR

COMA

SUSTAINED UNCONSIOUSNESS COMA A STATE OF SUSTAINED UNCONSIOUSNESS IN WHICH THE PATIENT DOES NOT RESPOND TO VERBAL STIMULI, MAY HAVE VARYING RESPONSES TO PAINFUL STIMULI, DOES NOT MOVE VOLUNTARILY, MAY HAVE ALTERED RESPIRATORY PATTERNS, MAY HAVE ALTERED PUPILLARY RESPONSES TO LIGHT, AND DOES NOT BLINK. (Black, 5 th edition)

COMA

A STATE OF SUSTAINED UNCONSIOUSNESS IN WHICH THE PATIENT DOES NOT RESPOND TO VERBAL STIMULI, MAY HAVE VARYING RESPONSES TO PAINFUL STIMULI, DOES NOT MOVE VOLUNTARILY, MAY HAVE ALTERED RESPIRATORY PATTERNS, MAY HAVE ALTERED PUPILLARY RESPONSES TO LIGHT, AND DOES NOT BLINK. (Black, 5 th edition)

BREATHING IN THE UNCONSCIOUS CLIENT Respiration controlled by cerebrum, pons and medulla Airway obstruction and aspiration common complications Obstructed airways causes  CO 2 retention  vasodilation  cerebral edema  increased ICP Reduced O 2 levels  less oxygen to brain  increased ICP

Respiration controlled by cerebrum, pons and medulla

Airway obstruction and aspiration common complications

Obstructed airways causes  CO 2 retention  vasodilation  cerebral edema  increased ICP

Reduced O 2 levels  less oxygen to brain  increased ICP

EYE MOVEMENTS IN THE UNCONSCIOUS CLIENT CN responsible for eye movement exit thru the brain stem. If compressed eye movement is impaired. Normally gaze straight ahead and track together In comatose client they are uncoordinated, and pupillary response is abnormal. (Eyes movements can be dysconjugate, ocular bobbing, roving, nystagmus).

CN responsible for eye movement exit thru the brain stem. If compressed eye movement is impaired.

Normally gaze straight ahead and track together

In comatose client they are uncoordinated, and pupillary response is abnormal. (Eyes movements can be dysconjugate, ocular bobbing, roving, nystagmus).

PUPILLARY CHANGES IN THE UNCONSCIOUS CLIENT Nuclei of CN11 and 111 located below cerebrum and in mid-brain Assessed for size, equality, reaction, responsive Fixed and dilated late signs of herniation and severe hypoxia Other causes Hypothermia, Medications, Lesions

Nuclei of CN11 and 111 located below cerebrum and in mid-brain

Assessed for size, equality, reaction, responsive

Fixed and dilated late signs of herniation and severe hypoxia

Other causes

Hypothermia, Medications, Lesions

MOTOR RESPONSES SEEN IN UNCONSCIOUSNESS POSTURING Decorticate Decerebrate Flaccidity (Unilateral or Bilateral) OTHER MOTOR SIGNS Primitive sucking or snout reflexes Strong reflexive hand grasps Restlessness Resistance to passive movements Hemiplegia Hemiparesis Seizures

POSTURING

Decorticate

Decerebrate

Flaccidity (Unilateral or Bilateral)

OTHER MOTOR SIGNS

Primitive sucking or snout reflexes

Strong reflexive hand grasps

Restlessness

Resistance to passive movements

Hemiplegia

Hemiparesis

Seizures

CHANGES IN VITAL SIGNS Wide variations may be seen with various levels of consciousness and some changes directly related to the cause of the unconsciouness Cushings (Triad) may develop with increased ICP Decreased pulse Increased systolic BP with same or slightly higher diastolic resulting in a widened Pulse Pressure Slow respirations

Wide variations may be seen with various levels of consciousness and some changes directly related to the cause of the unconsciouness

Cushings (Triad) may develop with increased ICP

Decreased pulse

Increased systolic BP with same or slightly higher diastolic resulting in a widened Pulse Pressure

Slow respirations

ASSESSING CONSCIOUSNESS

ASSESSING CONSCIOUSNESS

The Glasgow Coma Scale (GCS) Universally used Measures eye, verbal, and motor response Excellent scale to measure Arousal . Know the difference b/t content & arousal

GLASGOW COMA SCALE SCORE (GCS) Eyes 1 Closed at all times 2 Opens to pain 3 Opens to voice command 4 Open spontaneously Motor 1 No response 2 Extension (decerebrate rigidity) 3 Flexion posturing 4 Flexion withdrawal 5 Localizes painful stimulus 6 Obeys commands Verbal 1 No response 2 Incomprehensible sounds 3 Inappropriate words 4 Disoriented and converses 5 Oriented and converses 15 (top score) A score of 10 or less indicates a need for emergency attention A score less than 7 is interpreted as coma

 

CONTENT Besides orientation to time, place and person the following cognitive abilities should also be assessed: Attention and vigilance Memory – short, intermediate, long term Language – understanding of spoken and written word General fund of information Construction ability Sequencing activities Problem solving Abstraction Insight and judgement The Mini Mental Status Exam is an example of a test for cognitive function.

CONTENT

Besides orientation to time, place and person the following cognitive abilities should also be assessed:

Attention and vigilance

Memory – short, intermediate, long term

Language – understanding of spoken and written word

General fund of information

Construction ability

Sequencing activities

Problem solving

Abstraction

Insight and judgement

The Mini Mental Status Exam is an example of a test for cognitive function.

Any process that results in ↑ ICP will produce impairment of content and arousal . *** Remember restless and other changes in behavior frequently precede changes in vital signs, However, changes in LOC will occur first.

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