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The Plan  Neuroscience Nursing  Nursing Assessment in Acute Neurologic Injury  Correlational Neuroanatomy
The Plan  Neuroscience Nursing  Nursing Assessment in Acute Neurologic Injury  Correlational Neuroanatomy
The Plan  Neuroscience Nursing  Nursing Assessment in Acute Neurologic Injury  Correlational Neuroanatomy
The Plan  Neuroscience Nursing  Nursing Assessment in Acute Neurologic Injury  Correlational Neuroanatomy

The Plan

Neuroscience Nursing

Nursing Assessment in Acute Neurologic Injury

Correlational Neuroanatomy

Neuroscience Nursing Research

Evidence-based practice and neuroscience application of nursing research to the practice of neuroscience

Examples of nursing research in Neuroscience

DaiWai M. Olson PhD RN CCRN Assistant Professor of Medicine/Neurology
DaiWai M. Olson PhD RN CCRN Assistant Professor of Medicine/Neurology
DaiWai M. Olson PhD RN CCRN Assistant Professor of Medicine/Neurology
DaiWai M. Olson PhD RN CCRN Assistant Professor of Medicine/Neurology
DaiWai M. Olson PhD RN CCRN Assistant Professor of Medicine/Neurology

DaiWai M. Olson PhD RN CCRN

Assistant Professor of Medicine/Neurology

Disclosures

Disclosures Research Grant Recipient  Aspect Medical Systems  Alsius Medical  Amer. Assoc. Crit. Care
Research Grant Recipient  Aspect Medical Systems  Alsius Medical  Amer. Assoc. Crit. Care
Research Grant Recipient
 Aspect Medical Systems
 Alsius Medical
 Amer. Assoc. Crit. Care
 American Heart Assoc.
 Bristol-Meyers Squibb
 Edwards Lifesciences
 Hospira
 LiDCO Corporation
 Medicines Company
 Medtronic Corp.
 Nat. Inst. Health (NIH)
 Neuro. Nursing Foundation
 Sanofi Aventis
Speaker’s Bureau  Abbott Laboratories  Aspect Medical Systems  Alsius Medical  Barbara Clark-Mims
Speaker’s Bureau
 Abbott Laboratories
 Aspect Medical Systems
 Alsius Medical
 Barbara Clark-Mims Assoc.
 Hospira
 Medivance Corp
 USB – Pharma
 Zoll Medical
Stock/Financial interest • None
Stock/Financial interest
None

A B C D E F G H I J K L M N O

A B C D E F G H I J K L M N O 

Airway

Airway

B

C

C

B

irculation

reathing

Disability

Disability

Expose

Expose

 B  C  C  B irculation reathing  D isability  D isability
 B  C  C  B irculation reathing  D isability  D isability

Evidence

Circulation Airway - Breathing

Editorial Board

2010 AHA Guidelines for CPR and

Emergency care Science

2010

Circulation

Vol. 122

S640-S656

A B C D E F G H I J K L M N O

A B C D E F G H I J K L M N O

A B C D E F G H I J K L M N O 

Fahrenheit (temperature) Gadgets (your call) History (1 st assessment) Head - to Toe (every time) I.V. s (your call)

G adgets (your call)  H istory (1 s t assessment)  Head - to –
A B C D E F G H I J K L M N O

A B C D E F G H I J K L M N O

A B C D E F G H I J K L M N O 

Jackson-Pratt (all drains) Keep family informed Labs (due, done, & to treat) Medications (due, done & followup) New orders

A B C D E F G H I J K L M N O

A B C D E F G H I J K L M N O 

Okay Okay, move on Overview On top of it Other patients Other projects (chart)

L M N O  O kay  O kay, move on  O verview 
The great divide Upper motor neuron lesion Lower motor neuron lesion What is a “

The great divide

Upper motor neuron lesion

Lower motor neuron lesion

divide Upper motor neuron lesion Lower motor neuron lesion What is a “ lesion “ anyway

What is a

lesion

anyway ?

Non-specific term refers to any abnormal tissue

Evidence

Nurses differentiate UMN vs LMN

K. Clarke & T. Levine

Clinical Recognition and Management of

Amyotropic Lateral Sclerosis: The Nurse’s Role

2011

Journal of Neuroscience Nursing

Vol. 43 (4) pp 205-214

Upper or Lower ?

Lower motor neurons are:

From the SPINAL CORD to the MUSCLE

Upper or Lower ?  Lower motor neurons are: From the SPINAL CORD – to the

Upper or Lower ?

Upper motor neurons are:

From the BRAIN to the SPINAL CORD

NICE to KNOW

Efferent------

Afferent------

Lower ?  Upper motor neurons are: From the BRAIN – to the SPINAL CORD NICE

Upper or Lower Motor Neuron

Upper or Lower Motor Neuron We Upper Motor Present Lower Motor Present F No Yes A

We

Upper Motor

Present

Lower Motor

Present

F

No

Yes

A

No

Yes

R

Up

Down

T

Up

Down

Weakness

Fasciculations

Atrophy

Reflexes

Tone

The Case of J. P.
The Case of J. P.

Primary lesson is Nursing assessment

Highlighting Nursing Assessment
Highlighting
Nursing Assessment

Evidence

for telling “stories”

M. Sandelowski

We are the stories we tell

1994

Journal of Holistic Nursing

Vol. 12 (1) pp 23-33

What happened to J.P.? We need to understand 3 things 1. Cerebral artery circulation 2.
What happened to J.P.? We need to understand 3 things 1. Cerebral artery circulation 2.
What happened to J.P.? We need to understand 3 things 1. Cerebral artery circulation 2.
What happened to J.P.? We need to understand 3 things 1. Cerebral artery circulation 2.

What happened to J.P.?

We need to understand 3 things

1. Cerebral artery circulation

2. Cranial nerves

3. Do your damn job

to J.P.? We need to understand 3 things 1. Cerebral artery circulation 2. Cranial nerves 3.

Please

J.P.  20 year old G.I. return from Iraq  Prior to formation c/o “dizzy”
J.P.  20 year old G.I. return from Iraq  Prior to formation c/o “dizzy”
J.P.  20 year old G.I. return from Iraq  Prior to formation c/o “dizzy”
J.P.  20 year old G.I. return from Iraq  Prior to formation c/o “dizzy”

J.P.

20 year old G.I. return from Iraq

Prior to formation c/o “dizzy” and “thirsty”

Went for gatorade “tell everyone I went back”

Found unresponsive minutes later, minimal

respiratory effort, EMS called by C.O.

Transfer to Duke

Glasgow Coma Score = 3

Complete Basilar Artery Thrombosis

Complete Basilar Artery Thrombosis
MERCI  Merci retrieval  Returned to ICU
MERCI  Merci retrieval  Returned to ICU
MERCI  Merci retrieval  Returned to ICU
MERCI  Merci retrieval  Returned to ICU

MERCI

MERCI  Merci retrieval  Returned to ICU

Merci retrieval Returned to ICU

MERCI  Merci retrieval  Returned to ICU
ICU Day 1 32 C for 24 hours Day 2 wean paralytics passive rewarm on

ICU

Day 1

32 C for 24 hours

Day 2

wean paralytics passive rewarm on

Day 3

he returned to baseline temp, wean pressors

Day 4

ventric inserted (ICP =36) = GCS 4 , extensor

posturing, pupils sluggish, irreg shape, no dolls eyes, weak

gag, good cough

Day 5

See video on next slide for NIHSS exam

Day 5 = GCS from 3 8 Day 6 = GCS from 8 -10

ICU

 Day 5 = GCS from 3 – 8  Day 6 = GCS from 8
 Day 5 = GCS from 3 – 8  Day 6 = GCS from 8

Appearance

GCS / NIH

Cranial

Nerves

Motor

Aphasia

Appearance GCS / NIH Cranial Nerves Motor Aphasia H m m m ? ? ? Thalamus

H m m m ? ? ?

Thalamus Midbrain
Thalamus
Midbrain
Appearance GCS / NIH Cranial Nerves Motor Aphasia H m m m ? ? ? Thalamus

Pons

Appearance GCS / NIH Cranial Nerves Motor Aphasia H m m m ? ? ? Thalamus
Appearance GCS / NIH Cranial Nerves Motor Aphasia H m m m ? ? ? Thalamus
Appearance GCS / NIH Cranial Nerves Motor Aphasia H m m m ? ? ? Thalamus
Appearance GCS / NIH Cranial Nerves Motor Aphasia H m m m ? ? ? Thalamus

Medulla

Appearance GCS / NIH Cranial Nerves Motor Aphasia H m m m ? ? ? Thalamus

Cranial Nerves

Cranial Nerves 12 pairs Of Cranial Nerves In The Brain Stem Teaching Tip  Let’s Play
Cranial Nerves 12 pairs Of Cranial Nerves In The Brain Stem Teaching Tip  Let’s Play

12 pairs

Of

Cranial

Nerves

In The Brain Stem

Teaching Tip Let’s Play GOD

Cranial Nerves Playing GOD

Cranial Nerves – Playing GOD What is this? Midbrain Pons Medulla

What is this?

Cranial Nerves – Playing GOD What is this? Midbrain Pons Medulla

Midbrain

Pons

Medulla

Cranial Nerves Playing GOD

4 Midbrain Appearance 4 Pons GCS / NIH Cranial Nerves Medulla Motor 4 Aphasia
4
Midbrain
Appearance
4
Pons
GCS / NIH
Cranial
Nerves
Medulla
Motor
4
Aphasia

What Where would will you you put call 12 these nerves 12 nerves? ? How about 12 nerves - - - 3 places ? ? ?

1

2

3

4

5

6

7

8

9

10

11

12

Cranial Nerves Playing GOD

BONUS Question for GOD Where would you put #1, #2 I II III IV Midbrain
BONUS Question for GOD
Where would you put #1, #2
I
II
III
IV
Midbrain
Appearance
V
VI
VII
VIII
Pons
GCS / NIH
Cranial
Nerves
Medulla
Motor
IX
X
XI
XII
Aphasia

Etc?

Cranial Nerves

Cranial Nerves I Olfactory Smell II Optic Vision III Oculomotor Eye movement IV Trochlear

I

Olfactory

Smell

II

Optic

Vision

III

Oculomotor

Eye movement

IV

Trochlear

Eye movement

V

Trigeminal

Face/mouth

VI

Abducens

Eye movement

VII

Facial

expressions

VIII

Auditory hearing/balance

IX

Glossopharyngeal

Taste

X

Vagus

HR / BP

XI

Spinal Accessory

swallowing

XII

Hypoglossal

tongue movement

On Some Old Say Olympus Marry Towering Money Top But A My Friendly Brother
On Some Old Say Olympus Marry Towering Money Top But A My Friendly Brother
On Some Old Say Olympus Marry Towering Money Top But A My Friendly Brother
On Some Old Say Olympus Marry Towering Money Top But A My Friendly Brother

On

Some

Old

Say

Olympus

Marry

Towering

Money

Top

But

A

My

Friendly

Brother

Viking

Says

Grew

Bad

Vines

Business

And

My

Hops

Man

There

Are

Others

!

!

!

Evidence

for Cranial Nerve Assessment

T. Latha , R. Prakash , L.D. Josphine

Effectiveness of two Teaching Methods

for Cranial Nerve Assessment

2011

International Journal of Nursing Education

Vol. 3 (2) pp 65-69

CN I - Olfactory Characteristics: Sensory  Sense of smell Clinical Correlate  Injury will
CN I - Olfactory Characteristics: Sensory  Sense of smell Clinical Correlate  Injury will
CN I - Olfactory Characteristics: Sensory  Sense of smell Clinical Correlate  Injury will
CN I - Olfactory Characteristics: Sensory  Sense of smell Clinical Correlate  Injury will

CN I - Olfactory

Characteristics: Sensory

Sense of smell

Clinical Correlate

Injury will result in a loss of smell

I - Olfactory Characteristics: Sensory  Sense of smell Clinical Correlate  Injury will result in
CN II - Optic Characteristics: Sensory  Vision  Pupillary light reflex C l i
CN II - Optic Characteristics: Sensory  Vision  Pupillary light reflex C l i
CN II - Optic Characteristics: Sensory  Vision  Pupillary light reflex C l i
CN II - Optic Characteristics: Sensory  Vision  Pupillary light reflex C l i

CN II

- Optic

Characteristics: Sensory

Vision

Pupillary light reflex

Clinical Correlate

Injury will result in a loss of vision

Injury will cause a loss of pupil constriction to light (direct)

CN III
CN III
CN III
CN III
CN III - Oculomotor Characteristics: Motor  Motor of the oculo  Upward movement of
CN III - Oculomotor Characteristics: Motor  Motor of the oculo  Upward movement of
CN III - Oculomotor Characteristics: Motor  Motor of the oculo  Upward movement of
CN III - Oculomotor Characteristics: Motor  Motor of the oculo  Upward movement of

CN III - Oculomotor

Characteristics: Motor

Motor of the oculo

Upward movement of the eyeball

Raising the eyelid

Pupillary constriction with accomodation

the eyelid  Pupillary constriction with accomodation Clinical Correlate  Patients with CN III injury look

Clinical Correlate

Patients with CN III injury look down and out.

Injury causes diplopia

BLOWN PUPIL from CN III compression secondary to elevated ICP

III

Pupil = “little doll” ( latin pupilla)
Pupil = “little doll” ( latin pupilla)
Pupil = “little doll” ( latin pupilla)
Pupil = “little doll” ( latin pupilla)
Pupil = “little doll” ( latin pupilla)

Pupil = “little doll” (latin pupilla)

Swinging Flashlight - Test Normal Reaction
Swinging Flashlight - Test
Swinging Flashlight - Test

Normal Reaction

Swinging Flashlight - Test Normal Reaction
Swinging Flashlight - Test Normal Reaction
Swinging Flashlight - Test Normal Reaction
Swinging Flashlight - Test Normal Reaction
Swinging Flashlight - Test Marcus Gunn
Swinging Flashlight - Test
Swinging Flashlight - Test

Marcus Gunn

Swinging Flashlight - Test Marcus Gunn
Swinging Flashlight - Test Marcus Gunn
Swinging Flashlight - Test Marcus Gunn
Swinging Flashlight - Test Marcus Gunn
CN IV - Trochlear Characteristics: Motor  Rotation and adduction of the eye Clinical Correlate
CN IV - Trochlear Characteristics: Motor  Rotation and adduction of the eye Clinical Correlate
CN IV - Trochlear Characteristics: Motor  Rotation and adduction of the eye Clinical Correlate
CN IV - Trochlear Characteristics: Motor  Rotation and adduction of the eye Clinical Correlate

CN IV - Trochlear

Characteristics: Motor

Rotation and adduction of the eye

CN IV - Trochlear Characteristics: Motor  Rotation and adduction of the eye Clinical Correlate 

Clinical Correlate

Lazy downward gaze

CN IV - Trochlear Characteristics: Motor  Rotation and adduction of the eye Clinical Correlate 
Tri CN V - Trigeminal Characteristics: Both  Sensation (touch) face, scalp, cornea  Motor
Tri CN V - Trigeminal Characteristics: Both  Sensation (touch) face, scalp, cornea  Motor

Tri

CN V - Trigeminal

Characteristics: Both

Sensation (touch) face, scalp, cornea

Motor for chewing

Clinical Correlate

Injury results in loss of facial sensation, decreased direct corneal reflex

Partial facial paralysis

= three
= three
CN VI - Abducens Characteristics: Motor  Lateral movement of the eye Clinical Correlate 
CN VI - Abducens Characteristics: Motor  Lateral movement of the eye Clinical Correlate 
CN VI - Abducens Characteristics: Motor  Lateral movement of the eye Clinical Correlate 
CN VI - Abducens Characteristics: Motor  Lateral movement of the eye Clinical Correlate 
CN VI - Abducens Characteristics: Motor  Lateral movement of the eye Clinical Correlate 
CN VI - Abducens Characteristics: Motor  Lateral movement of the eye Clinical Correlate 
CN VI - Abducens Characteristics: Motor  Lateral movement of the eye Clinical Correlate 
CN VI - Abducens Characteristics: Motor  Lateral movement of the eye Clinical Correlate 

CN VI - Abducens

Characteristics: Motor

Lateral movement of the eye

Clinical Correlate

The patient can not look to the side with the affected eye (maintains peripheral vision)

the eye Clinical Correlate  The patient can not look to the side with the affected
The six cardinal fields of gaze
The six cardinal fields of gaze
The Visual Exam  Vision (CN II)  How many fingers do you see 
The Visual Exam  Vision (CN II)  How many fingers do you see 
The Visual Exam  Vision (CN II)  How many fingers do you see 
The Visual Exam  Vision (CN II)  How many fingers do you see 

The Visual Exam

Vision (CN II)

How many fingers do you see

Pupillary reflex (CN III)

Direct response to light

EOM’s (CN IV and CN VI) Follow my fingers as I make the letter “ N

Swinging flashlight

to light  EOM’s (CN IV and CN VI)  Follow my fingers as I make
CN VII - Facial Characteristics: Both  Sensory is taste on the front 2/3 of
CN VII - Facial Characteristics: Both  Sensory is taste on the front 2/3 of
CN VII - Facial Characteristics: Both  Sensory is taste on the front 2/3 of
CN VII - Facial Characteristics: Both  Sensory is taste on the front 2/3 of

CN VII

- Facial

Characteristics: Both

Sensory is taste on the front 2/3 of the tongue

Motor is for facial expression, eyelid closure and for both the lacrimal & salivary glands

Clinical Correlate

Injury leads to crocodile tears

Decreased taste sensation

Poor closure of the eye

7
7
CN VIII - Vestibulocochlear Characteristics: Sensory Clinical Correlate  Hearing  Equilibrium  Balance 
CN VIII - Vestibulocochlear Characteristics: Sensory Clinical Correlate  Hearing  Equilibrium  Balance 
CN VIII - Vestibulocochlear Characteristics: Sensory Clinical Correlate  Hearing  Equilibrium  Balance 
CN VIII - Vestibulocochlear Characteristics: Sensory Clinical Correlate  Hearing  Equilibrium  Balance 

CN VIII - Vestibulocochlear

Characteristics: Sensory

Clinical Correlate

Hearing

Equilibrium

Balance

Some feedback to compensatory eye movement (doll’s eyes)

Wobbly

Vertigo

Loss of hearing

Patients flip upside down in bed

eye movement (doll’s eyes)  Wobbly  Vertigo  Loss of hearing  Patients flip upside

8

CN IX - Glossopharyngeal G Characteristics: Both  Sensory – taste on posterior portion of

CN IX - Glossopharyngeal

G

Characteristics: Both

Sensory taste on posterior portion of tongue

Motor parotid gland

Clinical Correlate

Injury will result in a loss of taste

Loss of Gag reflex

= Gag

- Vagal Clinical Correlate CN X Characteristics: Both  Sensory – sensation of the pharynx
- Vagal Clinical Correlate CN X Characteristics: Both  Sensory – sensation of the pharynx
- Vagal Clinical Correlate CN X Characteristics: Both  Sensory – sensation of the pharynx
- Vagal Clinical Correlate CN X Characteristics: Both  Sensory – sensation of the pharynx

- Vagal

Clinical Correlate

CN X

Characteristics: Both

Sensory sensation of the pharynx & larynx & Carina

Loss of gag & cough reflex
Bradycardia

Motor swallowing, cardiac

& GI

CN XI - Accessory Characteristics: Motor  SCM and Trapezius Clinical Correlate  Injury will
CN XI - Accessory Characteristics: Motor  SCM and Trapezius Clinical Correlate  Injury will
CN XI - Accessory Characteristics: Motor  SCM and Trapezius Clinical Correlate  Injury will
CN XI - Accessory Characteristics: Motor  SCM and Trapezius Clinical Correlate  Injury will

CN XI - Accessory

Characteristics: Motor

SCM and Trapezius

Clinical Correlate

Injury will result in an inability to turn head or droopy shoulders

Accessorize !

and Trapezius Clinical Correlate  Injury will result in an inability to turn head or droopy
CN XII - Hypoglossal Characteristics: Motor C l i n i c a l C
CN XII - Hypoglossal Characteristics: Motor C l i n i c a l C
CN XII - Hypoglossal Characteristics: Motor C l i n i c a l C
CN XII - Hypoglossal Characteristics: Motor C l i n i c a l C

CN XII - Hypoglossal

Characteristics: Motor

CN XII - Hypoglossal Characteristics: Motor C l i n i c a l C o

Clinical Correlate

Injury will result in tongue deviation.

The tongue points to the weak side

This test may not be as clinically relevant as we want it to seem

I’m gonna go pretty fast!

I’m gonna go pretty fast! …but trust It’s gonna end up alright !

…but trust

It’s gonna end up alright !

The Case of Delia Washington
The Case of Delia Washington
Highlighting Aneurysms
Highlighting
Aneurysms
The Case of Delia Washington Highlighting Aneurysms Cerebral Arteries

Cerebral Arteries

Miss Delia  While at church c/o WHOL & DFO  Family rushed her to
Miss Delia  While at church c/o WHOL & DFO  Family rushed her to
Miss Delia  While at church c/o WHOL & DFO  Family rushed her to
Miss Delia  While at church c/o WHOL & DFO  Family rushed her to
Miss Delia  While at church c/o WHOL & DFO  Family rushed her to

Miss Delia

While at church c/o WHOL & DFO

Family rushed her to OSH Transfer to Duke as “probably an SAH”

GCS = 6 (E2, V1, M3[flexion])

DFO “she got all swimmy headed and done fell out”

Emergency Department  Rapid assessment A B C D  Stroke Code  Imaging (?WHY?
Emergency Department  Rapid assessment A B C D  Stroke Code  Imaging (?WHY?
Emergency Department  Rapid assessment A B C D  Stroke Code  Imaging (?WHY?
Emergency Department  Rapid assessment A B C D  Stroke Code  Imaging (?WHY?

Emergency Department

Rapid assessment A B C D

Stroke Code

Imaging (?WHY? Is imaging important)

Emergency Department  Rapid assessment A B C D  Stroke Code  Imaging (?WHY? Is
Imaging to rule out/in bleeding
Imaging to rule out/in bleeding
Imaging to rule out/in bleeding
Imaging to rule out/in bleeding

Imaging to rule out/in bleeding

Imaging to rule out/in bleeding
Imaging to rule out/in bleeding
Stroke  Ischemic  >24 hours = Acute ischemic Stroke (AIS)  <24 hours =
Stroke  Ischemic  >24 hours = Acute ischemic Stroke (AIS)  <24 hours =
Stroke  Ischemic  >24 hours = Acute ischemic Stroke (AIS)  <24 hours =
Stroke  Ischemic  >24 hours = Acute ischemic Stroke (AIS)  <24 hours =

Stroke

Ischemic

>24 hours = Acute ischemic Stroke (AIS)

<24 hours = Transient ischemic attack (TIA)

Hemorrhagic

Subarachnoid Hemorrhage (SAH)

Intracerebral Hemorrhage (ICH)

Evidence

Nursing Role in Emergence Stroke care

DM Olson, M Constable, G Britz, CB Lin, L Zimmer, LH Schwamm, GC Fonarow, ED Peterson

A Qualitative Assessment of Practices

Associated with Shorter Door-to-Needle Time of Thrombolytic Therapy in Acute Ischemic

Stroke

2011

Journal of Neuroscience Nursing

Vol. 43 (6) pp 329-336

Cerebral Aneurysm  Nearly 20 million Americans harbor an aneurysm  Annually 30,000 of these
Cerebral Aneurysm  Nearly 20 million Americans harbor an aneurysm  Annually 30,000 of these
Cerebral Aneurysm  Nearly 20 million Americans harbor an aneurysm  Annually 30,000 of these
Cerebral Aneurysm  Nearly 20 million Americans harbor an aneurysm  Annually 30,000 of these

Cerebral Aneurysm

Nearly 20 million Americans harbor an aneurysm

Annually 30,000 of these rupture resulting in subarachnoid hemorrhage (SAH)

Women affected more than men

Typically present between 35-60 years of age

Aneurysms A bubble in an artery caused by a weakening of the vessel wall .

Aneurysms

Aneurysms A bubble in an artery caused by a weakening of the vessel wall .

A bubble in an artery caused by a weakening of the vessel wall.

Delia  CT shows diffuse blood  Suspicious for aneurysm  Transfer to NeuroCritical Care
Delia  CT shows diffuse blood  Suspicious for aneurysm  Transfer to NeuroCritical Care
Delia  CT shows diffuse blood  Suspicious for aneurysm  Transfer to NeuroCritical Care
Delia  CT shows diffuse blood  Suspicious for aneurysm  Transfer to NeuroCritical Care

Delia

CT shows diffuse blood

Suspicious for aneurysm

Transfer to NeuroCritical Care Unit (NCCU)

Develops continually falling level of consciousness

Progression in weakness of her left arm.

Prep for ANGIOGRAM

Delia  Stabilize & prep for A-gram  Why A-gram and not O.R.
Delia  Stabilize & prep for A-gram  Why A-gram and not O.R.
Delia  Stabilize & prep for A-gram  Why A-gram and not O.R.
Delia  Stabilize & prep for A-gram  Why A-gram and not O.R.

Delia

Stabilize & prep for A-gram

Why A-gram and not O.R.

Delia  Stabilize & prep for A-gram  Why A-gram and not O.R.

Aneurysm treatment option

Coiling

Insertion of tiny platinum coils into the aneurysm, blocking blood flow to the

aneurysm.

If the aneurysm has a wide neck, a stent can be deployed

across the neck to keep the

coils in place.

http://www.brainaneurysm.com/aneurysm-

treatment.html

a stent can be deployed across the neck to keep the coils in place. http://www.brainaneurysm.com/aneurysm- treatment.html

Wide Neck Aneurysms can’t be

coiled - - -yet …

(sorta)

Wide Neck Aneurysms can’t be coiled - - - yet … ( sorta )
Wide Neck Aneurysms can’t be coiled - - - yet … ( sorta )
Hunt and Hess Score Hunt & Hess Grade 1 2 3 4 5 Description Asymptomatic,
Hunt and Hess Score Hunt & Hess Grade 1 2 3 4 5 Description Asymptomatic,
Hunt and Hess Score Hunt & Hess Grade 1 2 3 4 5 Description Asymptomatic,
Hunt and Hess Score Hunt & Hess Grade 1 2 3 4 5 Description Asymptomatic,

Hunt and Hess Score

Hunt & Hess Grade

1

2

Hunt & Hess Grade 1 2 3 4 5 Description Asymptomatic, mild headache, slight nuchal rigidity

3

4

5

Description

Asymptomatic, mild headache, slight nuchal rigidity

Moderate to severe headache, nuchal rigidity, no neurologic deficit

other than cranial nerve palsy

Drowsiness or confusion, mild focal neurologic deficit

Stupor, moderate to severe hemiparesis

Coma, decerebrate posturing

Fisher Scale Presence of Subarachnoid Blood Fisher Grade No blood on CT scan I Diffuse
Fisher Scale Presence of Subarachnoid Blood Fisher Grade No blood on CT scan I Diffuse
Fisher Scale Presence of Subarachnoid Blood Fisher Grade No blood on CT scan I Diffuse
Fisher Scale Presence of Subarachnoid Blood Fisher Grade No blood on CT scan I Diffuse

Fisher Scale

Presence of Subarachnoid Blood

Fisher Grade

No blood on CT scan

I

Diffuse blood, < 1 mm thick

II

Localized clot or think layer, >1 mm thick

III

Diffuse or none, with intracerebral or intraventricular blood

IV

WFNS SAH Grading Scale Grade G C S Motor Deficit I 15 None II 13
WFNS SAH Grading Scale Grade G C S Motor Deficit I 15 None II 13
WFNS SAH Grading Scale Grade G C S Motor Deficit I 15 None II 13
WFNS SAH Grading Scale Grade G C S Motor Deficit I 15 None II 13

WFNS SAH Grading Scale

Grade

G C S

Motor Deficit

I

15

None

II

13 14

None

III

13 14

Present

IV

7 12

None / Present

V

3 - 6

None / Present

World Federation of Neurological Societies

Delia  A-gram shows large right MCA aneurysm  Not amenable to coiling  Surgical
Delia  A-gram shows large right MCA aneurysm  Not amenable to coiling  Surgical
Delia  A-gram shows large right MCA aneurysm  Not amenable to coiling  Surgical
Delia  A-gram shows large right MCA aneurysm  Not amenable to coiling  Surgical

Delia

A-gram shows large right MCA aneurysm

Not amenable to coiling

Surgical ligation NOW

Surgery
Surgery

Surgery

Surgery
Case study - Delia 
Case study - Delia

Back from Surgery

NOW WHAT ? ? ? ?

What do we expect and why?

Vascular Anatomy There are two very common representations of the cerebral arteries. I find they

Vascular Anatomy

There are two very common representations of the cerebral arteries. I find they are both confusing. We’ll look at them

briefly and then

.

common representations of the cerebral arteries. I find they are both confusing. We’ll look at them
common representations of the cerebral arteries. I find they are both confusing. We’ll look at them
ACA MCA ACommA PCA Basilar
ACA MCA ACommA PCA Basilar
ACA
MCA
ACommA
PCA
Basilar
We are going to look at a series of slides that I created to look
We are going to look at a series of slides that I created to look
We are going to look at a series of slides that I created to look
We are going to look at a series of slides that I created to look

We are going to look at a series of slides that I created to look at circulation…. Try to focus on the ONE artery that I highlight in each slide

Vertebral Arteries
Vertebral Arteries
Vertebral Arteries
Vertebral Arteries
Vertebral Arteries

Vertebral Arteries

Basilar Artery
Basilar Artery
Basilar Artery
Basilar Artery
Basilar Artery

Basilar Artery

Internal Carotid Arteries

Internal Carotid Arteries

Anterior Communicating
Anterior Communicating
Anterior Communicating
Anterior Communicating
Anterior Communicating

Anterior Communicating

Posterior communicating
Posterior communicating
Posterior communicating
Posterior communicating
Posterior communicating

Posterior communicating

Anterior Cerebral Arteries
Anterior Cerebral Arteries
Anterior Cerebral Arteries
Anterior Cerebral Arteries
Anterior Cerebral Arteries

Anterior Cerebral Arteries

Middle Cerebral Arteries

Middle Cerebral Arteries

Posterior Cerebral Arteries
Posterior Cerebral Arteries
Posterior Cerebral Arteries
Posterior Cerebral Arteries
Posterior Cerebral Arteries

Posterior Cerebral Arteries

S.A.H. T.B.I.  Secondary Brain Injury What are we concerned with?  Secondary Brain Injury
S.A.H. T.B.I.  Secondary Brain Injury What are we concerned with?  Secondary Brain Injury
S.A.H. T.B.I.  Secondary Brain Injury What are we concerned with?  Secondary Brain Injury
S.A.H. T.B.I.  Secondary Brain Injury What are we concerned with?  Secondary Brain Injury

S.A.H.

T.B.I.

Secondary Brain Injury

What are we concerned with?

Secondary Brain Injury

ICP

 

ICP

Perfusion (PbtO2)

Perfusion (PbtO2)

Neuro exam

Neuro exam

Multi-modal monitoring

Multi-modal monitoring

Respond to changes

Respond to changes

Blood in subarachnoid space causes primary brain injury which through a variety of neurochemical changes causes a risk of secondary brain injury

Direct trauma to the skull/brain causes primary brain injury which through a variety of neurochemical changes causes a risk of secondary brain injury

* More alike then different
* More alike then different
Case study - Delia  Day 14 transfer to step down
Case study - Delia
Case study - Delia

Day 14 transfer to step down

Transition
Transition
Transition
Transition
Transition

Transition

The Case of Phineas Gage
The Case of Phineas Gage
Highlighting Functional Neuroanatomy
Highlighting
Functional Neuroanatomy

* * * Classic Case * * *

Phineas Gage (b. 1823 d.1860)

Phineas Gage (b. 1823 – d.1860)  Year 1848 (age 25)  The Foreman - Hard

Year 1848 (age 25)

The Foreman - Hard working, energetic, driven

Setting explosives in Vermont – for “Rutland and Burlington Railroad”

Phineas Gage (b. 1823 d.1860)

Phineas Gage (b. 1823 – d.1860) 1848 Wyatt Earp – born Wisconsin becomes the 30 th
1848 Wyatt Earp – born Wisconsin becomes the 30 th state
1848
Wyatt Earp – born
Wisconsin becomes
the 30 th state
Wyatt Earp – born Wisconsin becomes the 30 th state  The tamping iron for the

The tamping iron for the explosives reversed direction (caused by a spark) and shot through his skull and his frontal lobe.

Family prepared a coffin upon hearing of a fungal infection following surgery.

Phineas was “fine” as reported in 1949. But

Friends of gage, now state that Gage is no longer “Gage” .
Friends of gage, now state that Gage is no longer “Gage” .
Friends of gage, now state that Gage is no longer “Gage” .
Friends of gage, now state that Gage is no longer “Gage” .

Friends of gage, now state that

Harlow, J.M. (1868) Bulletin of Mass. Med. Society His contractors, who regarded him as the
Harlow, J.M. (1868) Bulletin of Mass. Med. Society His contractors, who regarded him as the
Harlow, J.M. (1868) Bulletin of Mass. Med. Society His contractors, who regarded him as the
Harlow, J.M. (1868) Bulletin of Mass. Med. Society His contractors, who regarded him as the

Harlow, J.M. (1868) Bulletin of Mass. Med. Society

His contractors, who regarded him as the most efficient and

capable foreman in their employ previous to his injury, considered the change in his mind so marked that they could not give him his place again. He is fitful, irreverent, indulging at times in the grossest profanity (which was not previously his

custom), manifesting but little deference for his fellows,

impatient of restraint of advice when it conflicts with his desires, at times pertinaciously obstinent, yet capricious and vacillating, devising many plans of future operation, which are no sooner arranged than they are abandoned in turn for others

appearing more feasible.

In this regard, his mind was radically changed, so decidedly that his friends and acquaintances said he was “no longer Gage.”

There are rumors about what happened to Gage. We know he did not get his
There are rumors about what happened to Gage. We know he did not get his
There are rumors about what happened to Gage. We know he did not get his
There are rumors about what happened to Gage. We know he did not get his
There are rumors about what happened to Gage. We know he did not get his

There are rumors about what happened to Gage.

We know he did not get his job

back. He is rumored to have traveled about with the tamping iron and sold himself (Barnum’s

Circus) as a novelty.

In 1860, living with his mother, he died of complications (aspiration) from an epileptic fit.

His body was exhumed in 1867 and his skull and the tamping iron are now at Harvard.

The

Frontal Lobe
Frontal
Lobe
The Frontal Lobe  Extends back to the central sulcus  executive functions  thought 
The Frontal Lobe  Extends back to the central sulcus  executive functions  thought 

Extends back to the central sulcus

executive functions

thought

Emotion

voluntary motor control

Contains the MOTOR STRIP

Start drawing your brain

Start drawing your brain

no too much “yet”

no too much “yet”

Frontal Lobe

Frontal Lobe
Frontal Lobe

Drawing class !

Central Sulcus
Central
Sulcus
Drawing class ! Central Sulcus
Drawing class ! Central Sulcus

Drawing class !

Central Sulcus
Central
Sulcus
Drawing class ! Central Sulcus Inferior Temporal Gyrus
Drawing class ! Central Sulcus Inferior Temporal Gyrus
Drawing class ! Central Sulcus Inferior Temporal Gyrus
Drawing class ! Central Sulcus Inferior Temporal Gyrus
Drawing class ! Central Sulcus Inferior Temporal Gyrus
Drawing class ! Central Sulcus Inferior Temporal Gyrus

Inferior Temporal Gyrus

Superior Frontal Gyrus  Higher cognitive functions  We are able to deduce and infer
Superior Frontal Gyrus  Higher cognitive functions  We are able to deduce and infer
Superior Frontal Gyrus  Higher cognitive functions  We are able to deduce and infer
Superior Frontal Gyrus  Higher cognitive functions  We are able to deduce and infer

Superior Frontal Gyrus

Higher cognitive functions

We are able to deduce and infer and plan

Frontal Gyrus  Higher cognitive functions  We are able to deduce and infer and plan

Working memory (later)

Frontal Gyrus  Higher cognitive functions  We are able to deduce and infer and plan

Higher cognitive function

Higher cognitive function Is it always a good thing? I am going to start the movie

Is it always a good thing? I am going to start the movie play close attention.

Middle Frontal Gyrus  We are not sure – yet  Maybe in decoding/encoding and
Middle Frontal Gyrus  We are not sure – yet  Maybe in decoding/encoding and
Middle Frontal Gyrus  We are not sure – yet  Maybe in decoding/encoding and
Middle Frontal Gyrus  We are not sure – yet  Maybe in decoding/encoding and
Middle Frontal Gyrus  We are not sure – yet  Maybe in decoding/encoding and
Middle Frontal Gyrus  We are not sure – yet  Maybe in decoding/encoding and

Middle Frontal Gyrus

Middle Frontal Gyrus  We are not sure – yet  Maybe in decoding/encoding and arbitration

We are not sure yet Maybe in decoding/encoding and arbitration

Your middle frontal gyrus tells you this is the letter .?
Your middle frontal gyrus
tells you this is the letter
.?
Inferior Frontal Gyrus  The go / no-go area  Response inhibition  Why we
Inferior Frontal Gyrus  The go / no-go area  Response inhibition  Why we
Inferior Frontal Gyrus  The go / no-go area  Response inhibition  Why we
Inferior Frontal Gyrus  The go / no-go area  Response inhibition  Why we

Inferior Frontal Gyrus

The go / no-go area Response inhibition

Why we stop walking when we hear a snake rattle

Frontal Gyrus  The go / no-go area  Response inhibition  Why we stop walking
Frontal Gyrus  The go / no-go area  Response inhibition  Why we stop walking

Homunculus

Motor homunculus

Homunculus Motor homunculus
Frontal Lobe – motor strip

Frontal Lobe motor strip

Premotor Cortex - Anatomy  Location  Within the frontal lobe  Anterior to the
Premotor Cortex - Anatomy  Location  Within the frontal lobe  Anterior to the

Premotor Cortex - Anatomy

Location

Premotor Cortex - Anatomy  Location  Within the frontal lobe  Anterior to the motor

Within the frontal lobe

Anterior to the motor strip

Premotor cortex - Function  Lateral Premotor Cortex  Intentional movements (preparation)  Triggered by
Premotor cortex - Function  Lateral Premotor Cortex  Intentional movements (preparation)  Triggered by
Premotor cortex - Function  Lateral Premotor Cortex  Intentional movements (preparation)  Triggered by
Premotor cortex - Function  Lateral Premotor Cortex  Intentional movements (preparation)  Triggered by

Premotor cortex - Function

Lateral Premotor Cortex

Intentional movements (preparation)

Triggered by visual cues

Baby claps when you clap

catch a ball

Premotor cortex - Function  Medial Premotor Cortex  Mediates movements  Triggered by internal
Premotor cortex - Function  Medial Premotor Cortex  Mediates movements  Triggered by internal
Premotor cortex - Function  Medial Premotor Cortex  Mediates movements  Triggered by internal
Premotor cortex - Function  Medial Premotor Cortex  Mediates movements  Triggered by internal

Premotor cortex - Function

Medial Premotor Cortex

Mediates movements

Triggered by internal cues

Your hand comes up to your mouth before you cough

Executive Function  Controls other functions. My intact executive function will tell my motor cortex
Executive Function  Controls other functions. My intact executive function will tell my motor cortex
Executive Function  Controls other functions. My intact executive function will tell my motor cortex
Executive Function  Controls other functions. My intact executive function will tell my motor cortex

Executive Function

Controls other functions. My intact executive function will tell my motor cortex to lift my hand of the hot stove, or will see a wall in front of me and tell my legs to stop moving.

The Case of Tan Tan
The Case of Tan Tan
Highlighting Functional Neuroanatomy
Highlighting
Functional Neuroanatomy
* * * Classic Case * * *
* * * Classic Case * * *
Who was Dr. Paul Broca?  Physician  (b. 1824 – d.1880)  Asylum 

Who was Dr. Paul Broca?

Physician

(b. 1824 d.1880)

Asylum

Bicetre Hospital (Paris)

Most famous resident

“the Marquis de Sade”

Hospital (Paris) Most famous resident – “the Marquis de Sade”  “speech pattern” recognize d in

“speech pattern” recognized in Tan Tan

19 t h Century BB (before Broca)  The gyri of the brain were drawn

19 th Century BB

(before Broca)

The gyri of the brain were drawn resembling intestines

Thought the gyri kept the “brain” warm

Focus on ventricles brainstem internal capsule

Late 1700 some thought that back of skull = vision

1861 Paul Broca performed an autopsy on “Tan Tan”

1865 Broca published a paper that there are many patients who

have lost speech and have left frontal lesions

First called “non-fluent aphasia”

Broca’s Aphasia  Patient can not name items (anomia)  Show objects “fingernail” “wedding ring”
Broca’s Aphasia  Patient can not name items (anomia)  Show objects “fingernail” “wedding ring”

Broca’s Aphasia

Patient can not name items (anomia)

Show objects “fingernail” “wedding ring”

There is no fluency to the speech pattern

Do the words flow together?

You can understand the patient

Often only 1 or 2 unrelated words“tan”

Unable to repeat phrases

Five Purple Monkeys

the patient  Often only 1 or 2 unrelated words“tan”  Unable to repeat phrases 
Wernicke’s Aphasia  Patient can not name items (anomia)  Show objects “fingernail” “wedding ring”

Wernicke’s Aphasia

Patient can not name items (anomia)

Show objects “fingernail” “wedding ring”

There is a fluency to the speech

Although it does not make sense, the

speech the patient produces is fluent

You can not comprehend the speech

May be some recognizable words, but

communication is not understood

Unable to repeat phrases

Five Purple Monkeys

May be some recognizable words, but communication is not understood  Unable to repeat phrases 
Bill  65 y.o . male with “over 50” caths and 3 dozen stents 
Bill  65 y.o . male with “over 50” caths and 3 dozen stents 
Bill  65 y.o . male with “over 50” caths and 3 dozen stents 
Bill  65 y.o . male with “over 50” caths and 3 dozen stents 

Bill

65 y.o. male with “over 50” caths and 3 dozen stents

Admit s/p tussive syncope and Left MCA acute ischemic stroke with tPA

NIHSS = 2 (R. Foot numbness & mild anomia)

The scan
The scan
The scan
The scan
The scan

The scan

Tan Tan - Aphasia Naming Fluency Comprehension --- --- Yes --- Yes --- --- Expressive
Tan Tan - Aphasia
Naming
Fluency
Comprehension
---
---
Yes
---
Yes
---
---
Expressive Aphasia
Global Aphasia
---
Yes
---
Yes
-
Maybe
Yes
Yes
---
Yes
Yes

Broca’s

(expressive)

Wernicke’s

(sensory receptive)

Transcortical

Motor

Transcortical

Sensory

Conduction

Anomic Aphasia

Repetition

---

---

Yes

Yes

---

Yes

Speech  Most often – but not always – left hemisphere  Pars triangularis through
Speech  Most often – but not always – left hemisphere  Pars triangularis through
Speech  Most often – but not always – left hemisphere  Pars triangularis through
Speech  Most often – but not always – left hemisphere  Pars triangularis through

Speech

Most often but not always left hemisphere

Pars triangularis through pars opercularis

Speech  Most often – but not always – left hemisphere  Pars triangularis through pars
This leads us to think about a new problem Overlapping function

This leads us to think about a new

problem

Overlapping function

So What ?  If one location deals with one function – then other locations
So What ?  If one location deals with one function – then other locations
So What ?  If one location deals with one function – then other locations
So What ?  If one location deals with one function – then other locations

So What ?

If one location deals with one function then other locations may similarly deal with separate functions.

other locations may similarly deal with separate functions. Hint: in the 21 s t century, we

Hint: in the 21 st century, we are reversing our thinking away from the one-to-one relationship

Transition ! ! !
Transition ! ! !
Transition ! ! !
Transition
!
!
!
The Case of Yoel
The Case of Yoel
Highlighting Visual Cortex
Highlighting
Visual Cortex
Yoel During World War I, Yoel was a first lieutenant in the British Army. As
Yoel
Yoel

During World War I, Yoel was a first lieutenant in the British Army. As was common during WWI, he was hit with very small bore lead

shot. The bullet penetrated the back of his

head. In the excitement of the battle he did not at first realize he had been hit, but he did

immediately note that he had visual field changes.

Yoel The Bullets used in WWI were considerably smaller than those used today, and also
Yoel The Bullets used in WWI were considerably smaller than those used today, and also
Yoel The Bullets used in WWI were considerably smaller than those used today, and also
Yoel The Bullets used in WWI were considerably smaller than those used today, and also

Yoel

The Bullets used in WWI

were considerably smaller than those used today, and

also had a lower spread

(we had not learned how to be as deadly).

The brain injuries were

highly localized.

Drawing class !

Drawing Class ! ! ! ?
Drawing Class ! ! !
?
The Occipital Lobe  Line from parieto-occipital sulcus to pre-occipital notch (like that helps!) 
The Occipital Lobe  Line from parieto-occipital sulcus to pre-occipital notch (like that helps!) 
The Occipital Lobe  Line from parieto-occipital sulcus to pre-occipital notch (like that helps!) 
The Occipital Lobe  Line from parieto-occipital sulcus to pre-occipital notch (like that helps!) 
The Occipital Lobe  Line from parieto-occipital sulcus to pre-occipital notch (like that helps!) 

The Occipital Lobe

Line from parieto-occipital sulcus to pre-occipital notch (like

that helps!)

Important for Vision

Interpreting visual input

Visual reflex

to pre-occipital notch (like that helps!)  Important for Vision  Interpreting visual input  Visual

Anatomy of the EYE

Anatomy of the EYE

X

X Word

Word

Lesion location determines deficit
Lesion location determines deficit
Lesion location determines deficit
Drawing Class - - -use your handouts

Drawing Class - - -use your handouts

Drawing Class - - -use your handouts
The Visual Exam  Visual acuity  Visual fields

The Visual Exam

Visual acuity

Visual fields

The Visual Exam  Visual acuity  Visual fields
Transition
Transition
Transition
Transition

Transition

transition

transition

Thanks ! DaiWai Olson Olson006@mc.duke.edu
Thanks ! DaiWai Olson Olson006@mc.duke.edu
Thanks ! DaiWai Olson Olson006@mc.duke.edu
Thanks ! DaiWai Olson Olson006@mc.duke.edu

Thanks !

DaiWai Olson

Olson006@mc.duke.edu

The Case of H.M.
The Case of H.M.
Highlighting Memory
Highlighting
Memory
* * * Classic Case * * *
* * * Classic Case * * *
H. M.  27 y.o. male  “H.M.”  intractable seizures  1953 = surgical

H. M.

27 y.o. male “H.M.”

intractable seizures

1953 = surgical resection (bitemporal lobectomy)

 1953 = surgical resection (bitemporal lobectomy) No more seizures !  BUT  No more
No more seizures !
No more seizures !

BUT

No more memory

“Thibodaux LA” & “Mom is Irish”

December 2 nd 2008 HM dies “Henry Molaison

H.M. Throughout his life, H.M. was extensively studied. Probably in more studies than any other

H.M.

Throughout his life, H.M. was extensively studied. Probably in more studies than any other human.

His memory was reduced to less than 5 minutes. No short term memory.

No long term memory.

Hippocampus Surgical removal of the hippocampi.

“Every day is alone by itself”

The Limbic System  A.K.A. “emotional system”  Olfactory cortex  Smell  Hippocampus 
The Limbic System  A.K.A. “emotional system”  Olfactory cortex  Smell  Hippocampus 

The Limbic System

A.K.A. “emotional system”

Olfactory cortex

Smell

Hippocampus

memory

Amygdala

Emotion

Hypothalamus

Homeostasis:

the quaalude of the limbic system

Coronal slice of the Amygdala In the next slide (animated) try to focus on structures
Coronal slice of the Amygdala In the next slide (animated) try to focus on structures
Coronal slice of the Amygdala In the next slide (animated) try to focus on structures
Coronal slice of the Amygdala In the next slide (animated) try to focus on structures
Coronal slice of the Amygdala In the next slide (animated) try to focus on structures

Coronal

slice of the

Amygdala

In the next slide (animated) try to focus on structures around the amygdala

Amygdala
Amygdala
Amygdala
Amygdala
Amygdala

Amygdala

Hippocampus  Required for making new memories  but not storing new memories.  Spatial

Hippocampus

Required for making new memories

but not storing new memories.

Spatial relationship.

but not storing new memories.  Spatial relationship. H.M. could not develop new memories … but
H.M. could not develop new memories … but he could develop new skills.

H.M. could not develop new memories … but he could develop new skills.

One such example is where he could draw objects in the mirror. Try it some
One such example is where he could
draw objects in the mirror.
Try it some
time !

Memory organization along temporal lobe

Subjects were asked questions & shown pictures that made them think about people,

animals, and tools

*considerable overlap*

“think of your first pet” could elicit, Dog – Heidi leash pet store mother etc.

Memory

Long Term Short Term Non- Declarative Sensory Working Declarative What is the ‘basic’ difference between
Long Term
Short Term
Non-
Declarative
Sensory
Working
Declarative
What is the ‘basic’
difference between
short term and long term memory?
Events
Procedural
Specific
Personal
S
k
i
l
l
s
experiences
Long Term Memory
“Schema theory”
Perceptual
Facts
“Chunking”
Representation
Memories
from S.T.M.
World, object
Are moved to L.T.M.
Perceptual
Language
priming
knowledge
And sorted into
Where they fit best and
Classic
Short Term Memory
Humans can have
About 7 +/- 2
“chunks”
Of information
At any given
One point
Added to existing
Chunks of data
To become
SCHEMA
Conditioning
In time
Conditioned
Response
Non-
associative
Learning
153
H
bit
ti
Chunking and memory
Chunking and memory
Chunking and memory
Chunking and memory

Chunking and memory

Chunking and memory
Key concepts in MEMORY  Perceptual priming – prior recent exposure affects the next action.
Key concepts in MEMORY  Perceptual priming – prior recent exposure affects the next action.
Key concepts in MEMORY  Perceptual priming – prior recent exposure affects the next action.
Key concepts in MEMORY  Perceptual priming – prior recent exposure affects the next action.

Key concepts in MEMORY

Perceptual priming prior recent exposure affects the next action.

“look at my new watch. I bought this watch at the watch store.”
“look at my new watch. I bought this watch at the watch store.”
Fill in the blanks:
Fill in the blanks:
bought this watch at the watch store.” Fill in the blanks:  Conditioned response – think

Conditioned response – think Pavlov’s Dog

Habituation – the more you do something…the lesser the response

Sensitization each stimulus brings a greater response

(“she’s touching me ! ! !”)

Memory

Long Term

Short Term

Declarative

Non-

Declarative

Sensory

Working

Events

Specific

Personal

experiences

Sensory Working Events Specific Personal experiences Procedural S k i l l s ***Short term

Procedural

S

k

i

l

l

s

experiences Procedural S k i l l s ***Short term memory is your desktop*** Facts or
***Short term memory is your desktop***
***Short term memory is your desktop***

Facts

or ignore.

World, object

Language

knowledge

Perceptual

Representation

Sensory = sensory information

(and shift to working)

is registered briefly. We selectively attend to this

Perceptual

priming

Example: you “hear” something, but don’t attend to it until your spouse

that?” then you suddenly “remember” it.

Classic

Conditioning

asks, “what was

Working = command and control

Example: I say something that reminds you of your shopping list. You put this idea in short-term working, get your list, add that item,

Conditioned

Response

and paper back.

remember to put the pen

*

Non-

associative

Learning

remember to put the pen * Non- associative Learning This is ONE model of short term

This is ONE model of short term memory

there are others

156

H

bit

ti

Nemo  “Dory”  No short-term memory  No “what” area?
Nemo  “Dory”  No short-term memory  No “what” area?
Nemo  “Dory”  No short-term memory  No “what” area?
Nemo  “Dory”  No short-term memory  No “what” area?
Nemo  “Dory”  No short-term memory  No “what” area?

Nemo

Nemo  “Dory”  No short-term memory  No “what” area?

“Dory” No short-term memory

No “what” area?

Short term memory – prefrontal Lobe

Short term memory prefrontal Lobe

Short term memory – prefrontal Lobe
Is there photographic memory?  The Savant Syndrome (aka idiot savant)  Males > females

Is there photographic memory?

The Savant Syndrome (aka idiot savant)

Males > females

1 in 10 autistics have some ‘savant’ syndrome

Most have very narrow skill set

The skills almost always are linked to phenomenal memory

We still don’t have theory as to how this works.

The savant syndrome: an extraordinary condition. A synopsis: past, present, future Darold A. Treffert. Phil. Trans. R. Soc. B 2009. 364, 1351-1357

Blind Tom  Born May 25 t h , 1849 “Thomas Green Bethune” was born
Blind Tom  Born May 25 t h , 1849 “Thomas Green Bethune” was born
Blind Tom  Born May 25 t h , 1849 “Thomas Green Bethune” was born
Blind Tom  Born May 25 t h , 1849 “Thomas Green Bethune” was born

Blind Tom

Born May 25 th , 1849 “Thomas Green Bethune” was born blind a slave in Georgia.

Spoke early, and in

perfect tone and pitch

but inappropriately.

Mother “taught him like you would a horse” Played several instruments having heard a song only once.

 Mother “taught him like you would a horse”  Played several instruments having heard a

Memory

Long Term Short Term Non- Declarative Sensory Working Declarative Events Procedural Specific Personal S k
Long Term
Short Term
Non-
Declarative
Sensory
Working
Declarative
Events
Procedural
Specific
Personal
S
k
i
l
l
s
experiences
Perceptual
Facts
Representation
Let’s
put this all
World, object
Perceptual
Language
priming
knowledge
back together
Classic
Conditioning
Conditioned
Response
Non-
associative
Learning
H
bit
ti

161

Temporal lobe
Temporal lobe
Temporal lobe
Temporal lobe
Temporal lobe
Temporal lobe

Temporal lobe

Anatomy hint: think “ Sylvian Fissure”
Anatomy hint: think “ Sylvian Fissure”
Anatomy hint: think “ Sylvian Fissure”
Anatomy hint: think “ Sylvian Fissure”
Anatomy hint: think “ Sylvian Fissure”

Anatomy hint: think Sylvian Fissure”

Transition : The Ponzo illusion

Transition : The Ponzo illusion The lines are actually the same length. It becomes hard because

The lines are actually the same length. It becomes hard because you can only activate one visual pathway at once and that gets

stored in short-term memory.

Correlative Neuroanatomy 1. Left vs Right   A. Motor & Sensory B. Logic vs. Emotion
Correlative Neuroanatomy 1. Left vs Right   A. Motor & Sensory B. Logic vs. Emotion
Correlative Neuroanatomy 1. Left vs Right   A. Motor & Sensory B. Logic vs. Emotion
Correlative Neuroanatomy 1. Left vs Right   A. Motor & Sensory B. Logic vs. Emotion

Correlative Neuroanatomy

1.

Left vs Right

 

A. Motor & Sensory

B. Logic vs. Emotion

2.

Key locations

 

A.

Occipital vision

B.

Frontal motor & premotor

C.

Motor STRIP

D.

Speech & Language

3.

Neuroanatomist have ZERO imagination

End of Part 1
End of Part 1
End of Part 1
End of Part 1

End of Part 1

Neuroscience Nursing Research
Neuroscience Nursing Research
Neuroscience Nursing Research
Neuroscience Nursing Research

Neuroscience

Nursing

Research

? Systematic Review Randomized Clinical Trial Non-experimental research
?
Systematic
Review
Randomized
Clinical Trial
Non-experimental
research
Clinical Reports Nursing Experience
Clinical Reports Nursing Experience

Clinical Reports

Nursing Experience

Clinical Reports Nursing Experience
Clinical Reports Nursing Experience

Textbooks

The Religion of Science beliefs”

“opinions &

Belief Textbook - Experience

Turning the patient from side to side

Talking to patients when giving a bath

Giving pills with a break in between

Sit on the edge of the bed before standing up

Skin care

Vitals every hour (or 2-hours, or 15-minutes)

Making assignments

Monitor on/off at end-of-life

CSF drainage

Etc. etc. etc.

Tradition Tradition Just because you’ve always done it that way Doesn’t mean it is not
Tradition Tradition Just because you’ve always done it that way Doesn’t mean it is not

Tradition

Tradition Tradition Just because you’ve always done it that way Doesn’t mean it is not incredibly

Tradition

Just because you’ve always done it that way

Doesn’t mean it is not incredibly stupid

 Belief is usually something we develop before we start nursing school  Textbooks are
 Belief is usually something we develop before we start nursing school  Textbooks are
 Belief is usually something we develop before we start nursing school  Textbooks are
 Belief is usually something we develop before we start nursing school  Textbooks are

Belief is usually something we develop

before we start nursing school

Textbooks are most often at least 3 years

out of date (closer to 5+)

Experience can be good or bad

Nursing Experience Textbooks The Religion of Science beliefs” “opinions &
Nursing Experience
Textbooks
The Religion of Science
beliefs”
“opinions &
Experience is really the foundation Not a bad start…but… Is this EVIDENCE
Experience is really the foundation Not a bad start…but… Is this EVIDENCE
Experience is really the foundation Not a bad start…but… Is this EVIDENCE
Experience is really the foundation Not a bad start…but… Is this EVIDENCE
Experience is really the foundation Not a bad start…but… Is this EVIDENCE

Experience is really the foundation

Not a bad start…but…

Is this EVIDENCE

? Systematic Review Randomized Clinical Trial Non-experimental research Clinical Reports Nursing Experience
?
Systematic
Review
Randomized
Clinical Trial
Non-experimental
research
Clinical Reports
Nursing Experience
Textbooks

The Religion of Science beliefs”

“opinions &

Evidence Based Practice

“A shift in the culture of healthcare provision away

from basing decisions on opinion, past practice and

precedent toward making more use of science, research and evidence to guide clinical decision

making”

toward making more use of science, research and evidence to guide clinical decision making” (Appleby et

(Appleby et al, 1995)

NOT Practice “ Based on Evidence ”
NOT Practice “ Based on Evidence ”
NOT Practice “ Based on Evidence ”
NOT Practice “ Based on Evidence ”

NOT

Practice “Based on Evidence

NOT Practice “ Based on Evidence ”

Evidence Based Practice

The process of disseminating & using research-generated information to make an impact on or change in existing

health care practices

& using research-generated information to make an impact on or change in existing health care practices
Evidence Based Health Care “ an approach to health care that promotes the collection, interpretation
Evidence Based Health Care “ an approach to health care that promotes the collection, interpretation

Evidence Based Health Care

“ an approach to health care that promotes the collection,

interpretation and integration of valid, important and applicable patient-reported, clinician-observed and research-derived evidence”

important and applicable patient-reported, clinician-observed and research- derived evidence” (McKibbon et al, 1995)

(McKibbon et al, 1995)

Evidence Based Practice

Evidence Based Practice “the conscientious, explicit and judicious use of current best evidence about the care

“the conscientious, explicit and judicious use of current best evidence about the care of individual patients”

(Sackett et al, 1996)

Evidence-Based Practice Evidence-Based Nursing

“Process by which nurses make clinical decisions using the best available research evidence, their clinical
“Process by which nurses make
clinical decisions using the best
available research evidence, their
clinical expertise and patient
preferences”
?
?

Systematic

Review

Randomized Clinical Trial

Non-experimental

research

Clinical Reports

Nursing Experience

Textbooks

The Religion of Science beliefs”

“opinions &

In real life

The answer is not

always so easy !
always so easy !
Her own horse Small group
Her own horse
Small group

~42 y.o. female - Experienced rider

This story just does not make sense

own horse Small group ~42 y.o. female - Experienced rider This story just does not make

Neither does her CT Scan

CT Scan reveals diffuse edema &

small left frontal SDH

CT Scan reveals diffuse edema & small left frontal SDH When the Scan does not match

When the Scan does not match the story One of them is probably wrong

    ICP   MAP   N  s.d. 95%CI  s.d. 95%CI Before CPT
    ICP   MAP   N  s.d. 95%CI  s.d. 95%CI Before CPT
    ICP   MAP   N  s.d. 95%CI  s.d. 95%CI Before CPT
    ICP   MAP   N  s.d. 95%CI  s.d. 95%CI Before CPT
    ICP   MAP   N  s.d. 95%CI  s.d. 95%CI Before CPT
   

ICP

 

MAP

 

N

s.d.

95%CI

s.d.

95%CI

Before CPT

46

25.6

8.4

± 2.49

91.82

12.26

± 3.48

During

48

23.0

9.57

± 2.77

91.73

10.48

± 3.04

After CPT

50

17.3

7.15

± 2.03

90.08

9.95

± 2.83

Steady decrease in ICP associated with a NURSING intervention.

? Systematic Review Randomized Clinical Trial Non-experimental research Clinical Reports
?
Systematic
Review
Randomized
Clinical Trial
Non-experimental
research
Clinical Reports
Nursing Experience Textbooks
Nursing Experience Textbooks

Nursing Experience

Textbooks

Nursing Experience Textbooks
Nursing Experience Textbooks

The Religion of Science beliefs”

“opinions &

Two Kinds of Statistics

Descriptive Statistics
Descriptive Statistics

Organizing summarizing and describing a batch of data

means, standard deviations, frequencies, percents

charts and graphs

Inferential Statistics
Inferential Statistics

Methods of drawing conclusions about a population based on a sample from that population using a statement of probability

Both involve SAMPLING

Hypothesis Testing

Typical steps

1.

Design the study & state the hypothesis

2.

Collect data

3.

Determine the test statistic

4.

State the distribution when Ho is true

5.

State the decision rule