cognition

COGNITION PORT

CMS Objectives

  • CMS1: Interpret common clinical manifestations of Impaired Intracranial Regulation with a focus on the selected exemplars.

  • CMS2: Interpret laboratory and diagnostic studies for patients with Impaired Intracranial Regulation.

  • CMS3: Develop individualized teaching plan, utilizing current research, for patients with actual or risk for Impaired Intracranial Regulation.

  • CMS4: Plan and prioritize nursing care for patients with actual or risk for Impaired Intracranial Regulation.

  • CMS5: Identify modifiable and non-modifiable risk factors for developing Impaired Intracranial Regulation.

  • CMS6: Discuss common pharmacologic management for chosen exemplars of Impaired Intracranial Regulation.

Student Learning Outcomes

Nursing Concept of Cognition

  • Definition: The mental action or a process of knowing, involving several key elements:

    • Language

    • Learning

    • Perception

    • Memory

    • Social Cognition

    • Complex Attention

    • Executive Function

    • Perceptual Motor Function

Interrelated Concepts

  • Mobility

  • Nutrition

  • Glucose Regulation

  • Fluid and Electrolytes

  • Functional Ability

  • Cognition

  • Development

  • Gas Exchange

  • Perfusion

  • Acid-Base Balance

Health Promotion Older Adults

  • Fall Prevention: Emphasis on precautions to avoid falls.

  • Adhering to Cautions with Prescription Medications: Importance of compliance with medications.

  • Medical Alert Bracelets: Essential for patients at risk for impaired intracranial regulation.

  • School/Workplace Care Plans: Importance of discussing care plans in environments where the patient spends time.

  • Helmet Use for Young Children: Prevents head injury during seizure activities.

  • Patient Teaching related to Treatment Regimens: Focus on the side effects of prescription and over-the-counter medications.

  • Avoidance of Alcohol and Nicotine Products: Important to prevent exacerbation of neurological issues.

Cognitive Nursing Assessment

  • Assess level of alertness and orientation:

    • Person, Place, and Time

    • Glasgow Coma Scale

  • Observe for:

    • Patient’s appearance and dress

    • Facial movements and speech patterns

    • General comprehension of instructions

  • Collect general questions regarding:

    • History of neurological illness, seizures

    • Changes in vision, hearing, smell, balance, coordination

    • Memory complaints, pain complaints

Nursing Assessment

  • Conduct a physical examination:

    • Vital signs monitoring

    • Mental status evaluation

    • Cranial nerve assessments (Table 27.1, Giddens PG. 262)

    • Reflexes testing

    • Cerebellar function assessment (Table 13.1 PG. 115, Giddens)

    • Note symmetry of body sides

Cranial Nerve Assessment

CN

Sensory

Motor

I

Olfactory

Smell

II

Optic

Vision

III

Oculomotor

PERLA, Lid elevation, Eye movement

IV

Trochlear

Eye movement

V

Trigeminal

Cornea, Face, Mastication

VI

Abducens

Eye movement

VII

Facial

Taste (anterior 1/3 tongue), Facial expressions

VIII

Acoustic

Hearing, Equilibrium

IX

Glossopharyngeal

Taste (posterior tongue), Swallowing

X

Vagus

External ear, Swallowing, Phonation

XI

Spinal Accessory

Neck, Shoulder

XII

Hypoglossal

Tongue movement

Pupillary Assessment

  • Includes:

    • Direct Light Reflex

    • Consensual Light Reflex

    • Accommodation

    • PERRLA: Pupils Equal, Round, Reactive to Light and Accommodation.

    • EOMs: Extraocular Movements

Cerebellar Function Assessment

  • Evaluate:

    • Muscle coordination

    • Gait

    • Equilibrium

    • Ataxia

Reflex Activity Assessment

  • Normal Reflexes:

    • Blink

    • Gag

    • Corneal

    • Abdominal

    • Cremasteric

  • Abnormal Reflexes:

    • Babinski

    • Doll’s Eyes

Diagnostic Tests

  • Imaging:

    • CT Scan

    • MRI

    • X-Ray

  • Electrophysiological Tests:

    • EEG

    • Cerebral Angiography

    • Positron Emission Tomography (PET) Scan

    • Nerve Conduction Studies

  • Laboratory Tests:

    • Serum Electrolytes

    • Serum Glucose Testing

    • CSF Assessment

    • Therapeutic Drug Level Monitoring

    • ICP Monitoring

Lifespan Considerations Older Adults

  • Normal age-related sensory and neurological changes:

    • Often go unnoticed but include memory loss, with subtle changes in coordination.

    • Slower reflexes and reaction times observed.

    • Declines in mental status are not deemed normal with aging.

    • Intelligence and learning abilities typically remain unaltered.

    • Sensory impairments may be present.

Intracranial Regulation

  • Composition:

    • Cerebrospinal Fluid: 10%

    • Intravascular Blood: 12%

    • Brain Tissue: 78%

  • Balance of these components maintains ICP under normal conditions.

Intracranial Pressure Definitions

  • Intracranial Pressure (ICP): The pressure within the cranium exerted by the following components:

    • Brain

    • Blood

    • Cerebrospinal Fluid (CSF)

  • Normal adult ICP is between 5-15 mmHg.

  • Cerebral Perfusion Pressure (CPP): The amount of blood flow needed to provide adequate oxygen and glucose for brain metabolism.

Alterations in Intracranial Regulation

  • May result from illness or injury.

  • Assessment helps to determine the extent of cerebral dysfunction, generally follows a predictable stepwise progression:

    • Behavioral changes

    • Alterations in level of consciousness (LOC)

    • Decreased consciousness

    • Neurological dysfunctions

    • Hemodynamic instabilities apparent as damage progresses in primitive brain areas.

Increased Intracranial Pressure (IICP) - Cushing's Triad

  • Symptoms of IICP are Opposite of Shock:

    • Increased Systolic Blood Pressure

    • Decreased Pulse

    • Decreased Respirations

    • Significant medical education notes (Miller 2021) regarding shock conditions.

Progression of Deteriorating Brain Function

  • Consciousness Stages:

    1. Full Consciousness: Alert and oriented to time, place, person.

    2. Lethargy: Responds to verbal stimuli, shows decreased concentration, agitation, confusion; disoriented.

    3. Obtunded: Requires continuous stimulation to arouse.

    4. Pain Stimulus: Displays reflexive positioning to pain stimulus.

    5. Unresponsive: Shows no response to stimuli.

Glasgow Coma Scale

Response

Eye Opening

Motor Response

Verbal Response

4

Spontaneous

Follows commands

Oriented to person, place, and time

3

Response to speech

Local movement to pain

Confused

2

Response to pain

Nonpurposeful movement to stimuli

Incomprehensible sounds

1

No response

No response

No response

Posturing

Decorticate Posturing

  • Flexion

  • Plantar flexion

  • Extension

  • Flexion Adduction

Decerebrate Posturing

  • Plantar flexion

  • Extension

  • Flexion Pronation Adduction

  • Extension

Exemplar 13.F - Parkinson’s Disease

Overview

  • A progressive, degenerative neurologic disorder primarily affecting movement:

    • Characterized by:

    • Tremors: Begins with unilateral hand tremor, progressing to bilateral.

    • Muscle Rigidity

    • Bradykinesia: Slow movement.

    • Postural instability.

Pathophysiology

  • Progressive Loss of Dopaminergic Neurons in the Substantia Nigra.

  • Results in a decrease of dopamine content and presence of Lewy bodies in neurons:

    • Loss of dopaminergic neurons leads to abnormal nerve-firing patterns, resulting in impaired movement.

    • Degeneration of dopamine neurons increases acetylcholine signaling, creating a dopamine-acetylcholine imbalance.

Etiology

  • Exact cause is unknown, likely a combination of genetic susceptibility and environmental factors:

    • Some cases appear hereditary.

    • Risk increases with age, more prevalent in men.

    • Linked to living in rural areas and certain occupations.

  • Prevention: No definitive methods; emphasis on a healthy diet and nutritional supplements.

Motor Symptoms

  • Tremor: Early sign typically in one hand, prominent at rest; includes pill-rolling motion.

  • Rigidity: Cogwheel rigidity characterized by short, jerky movements of the arm.

  • Bradykinesia: Impacts both voluntary and automatic movements.

  • Increased difficulty with activities of daily living (ADLs), speech, and swallowing.

  • Postural Instability: Difficulty maintaining posture, risk of falls.

Key Features

  • Facial Symptoms: Mask-like facies, drooling, difficulty chewing and swallowing, speech issues (soft, low-pitched dysarthria).

  • Postural Instability: Stooped/trunk flexed posture, abduction/flexion of fingers, drooling.

  • Autonomic Dysfunctions: Include postural hypotension, excessive perspiration, oily skin, constipation, and psychological impacts.

Diagnosis

  • Utilizes medical history, neurological, and physical examinations:

    • Diagnostics include DATSCAN for visualization of dopaminergic neurons, MRIs, and blood tests to rule out other symptoms.

Treatment

  • Surgical Options: Reserved for advanced disease, primarily Deep Brain Stimulation (DBS) to send electrical signals to brain regions to reduce tremors, bradykinesia, or rigidity.

  • Pharmacological Treatments:

    • Goal: Correct dopamine imbalance

    • Common Medications:

    • Levodopa + Carbidopa (Sinemet)

    • Dopamine Agonists: Bromocriptine, Ropinirole, Pramipexole

Non-Pharmacological Therapy

  • Essential parts of treatment include exercise, physical therapy, and occupational therapy to improve flexibility, balance, muscle strength, posture.

Nursing Process

  • Assess:

    • Patient’s ability to perform ADLs and ambulate independently, look for changes in symptoms and medication effectiveness.

Diagnosis and Planning

  • Common diagnoses may include:

    • Risk for falls, impaired physical mobility, deficient self-care, disturbed sleep patterns.

  • Goals may focus on enabling independence, improving mobility and nutrition, integrating physical therapy, occupational therapy, and encouraging emotional support.

Migraines

Classification

  • Categories:

    • With Aura (Classic)

    • Without Aura (Common)

    • Atypical

Stages of Classic Migraines

  1. Prodromal Stage: Preceding phase with warning signs.

  2. Headache Phase: The intense pain phase.

  3. Recovery Phase: Easing of symptoms.

Common Migraines

  • Not preceded by an aura.

  • Usually last 4-72 hours with throbbing pulsating pain, typically unilateral.

  • Common symptoms include nausea, vomiting, and sensitivity to light and sound.

Cluster Headaches

  • Characterized by excruciating and unilateral pain without an aura, often accompanied by facial symptoms such as ptosis and lacrimation.

  • Recur in clusters.

Migraines Pathology

  • Chronic episodic disorder with unclear pathology but potential etiologies include familial/genetic components and environmental triggers.

Assessment

  • Focus on:

    • Description of the pain (type, frequency, duration).

    • Identifying triggers and relieving/aggravating factors.

    • Family history and associated symptoms affecting ADLs.

Non-Pharmacological Management

  • Prevention strategies:

    • Identify triggering factors, maintain a proper diet, incorporate relaxation techniques, meditation, acupuncture, and proper sleep habits.

Pharmacological Management

  • Preventative Medications: Beta-blockers, Calcium channel blockers, Antidepressants, Antiepileptics (Topamax).

  • Abortive Therapy: NSAIDs, ergots, triptans, and antiemetics.

Exemplar 11.B - Seizure Disorders

Overview

  • Seizures are periods of abnormal electrical discharges in the brain leading to involuntary movements, and behavioral/sensory alterations, prevalent in older adults and younger children.

  • Epilepsy involves recurrent seizures due to CNS disorders.

Pathophysiology and Etiology

  • Seizures arise from excessive electrical discharges on the brain's surface, can be focal (affecting limited brain areas) or generalized (affecting both hemispheres).

  • Focal Seizures: Can be simple (no effect on awareness) or complex (affecting awareness/memory).

Generalized Seizures

  • Tonic-Clonic Seizures: Involves a tonic phase (rigidity), clonic phase (rhythmic contraction), and postictal phase (lethargy, weakness).

  • Absence Seizures (Petit Mal): Brief LOC without aura.

Focal Seizures

  • Complex focal seizures may involve automatism.

  • Simple focal seizures lack LOC but show unilateral movements of an extremity.

Pharmacological Management

  • Focuses on seizure control, not cure, with antiepileptic drug therapy (AEDs) being commonly employed (e.g., Carbamazepine, Gabapentin, Levetiracetam).

Nursing Process

  • Ensure patient safety during seizures, document seizure characteristics, and monitor for postictal symptoms.

Diagnosis and Expected Outcomes

  • Expected outcomes include maintaining safety and preventing injury, achieving effective seizure control, and supporting emotional well-being.

Status Epilepticus

  • A medical emergency characterized by seizures longer than 5 minutes or repeated seizures over 30 minutes, requiring immediate pharmacological intervention.

Exemplar 16.M - Stroke

Overview

  • A cerebrovascular accident (CVA), with sided neurologic deficits due to decreased blood flow to a brain area.

  • Can present as ischemic (85% of cases) or hemorrhagic strokes (15%).

Risk Factors

  • Factors include hypertension, heart disease, diabetes, obesity, and a sedentary lifestyle.

Stroke Symptoms

  • Present with weakness, confusion, difficulty speaking, visual disturbances, and severe headaches, often assessed using the FAST mnemonic.

Management

  • Acute management involves rapid identification, transport to a stroke center, and possible intervention with IV thrombolytics within designated timelines.

Surgical Treatments

  • Include mechanical thrombectomy in cases of large vessel occlusion after clot extraction has been considered.

Conclusion

  • Includes ongoing education regarding risk modification, symptom identification, and supporting rehabilitation approaches.