Neuro Assessment

Megan McClintock, MS, RN10/27/11

Neurotransmitters Acetylcholine (activates muscles)

Decreased in AD, MG Dopamine (affects mood)

Decreased in PD

Lower motor neuron lesions Cause weakness or paralysis Denervation atrophy Flaccidity, hyporeflexia

Upper motor neuron lesions Cause weakness or paralysis Disuse atrophy Spasticity

Peripheral Nervous System

Spinal NervesANSSensory fibersMotor fibersDermatomes/myotomes

Cranial Nerves

ANSSympatheticParasympathetic

Vertebral Column

Assessment

Cerebral function (mental status) General appearance/behavior Cognition Mood/affect

Cranial nerves

Motor system Weakness (pronator drift) Muscle tone Balance/coordination (cerebellar function)

Sensory system Touch, pain, temp, vibration Position (Romberg test)

Reflexes

Diagnostic Studies

Lumbar Puncture

Cerebral Angiography

CT

MRI & MRA

PET & SPECT

Myelogram

EEG

EMG

Ultrasound

Headache

Common source of pain

PrimaryTensionMigraineCluster

SecondarySymptom of other primary disease process

Tension Headache

Pain is bilateral

“Squeezing” or “tight band” sensation

Mild to moderate intensity

Unaffected by activity

No prodrome, no nausea or vomiting

May have photophobia and/or phonophobia

Migraine Headache

Stages of Migraine

Prodrome

Aura (classic migraine, 10%)

Headache

Resolution

Interval

How do you know it’s a migraine?

More than 5 occurrences

Lasts 4-72 hours

Has at least 2 of these symptoms Unilateral Pulsating Nausea and/or vomiting Moderate to severe intensity Worse with physical activity

Photophobia/phonophobia

Not caused by other problems

Cluster Headaches

Headache Loci

Headache as Symptom

Brain tumor

Trigeminal neuralgia

Tooth impaction

Viral illness

Sinus infection

Subarachnoid hemorrhage

CO poisoning

Altitude sickness

Arteritis

Headache Medications

Tension Nonopioid analgesics Sedative, muscle relaxant, tranquilizer or codeine Fiorinal (can be habit forming)

Migraine Triptans (cause vasoconstriction) Preventive drugs (Topamax, Depakote)

Cluster 100% oxygen Triptans

Headache Interventions

Thorough assessment

Daily exercise

Relaxation techniques

Quiet, dimly lit environment

Massage

Moist hot packs

Dietary counseling

Medications

Seizure Disorders

Dysfunctional neuronal firing in one or more lobes of the brain Frontal Temporal Parietal Occipital

Causes of Seizures

Epilepsy

Brain injury

Infection

Genetic abnormality

Seizures as Symptoms

Hypoxia

Hypoglycemia

Drug & alcohol withdrawal

Acidosis

Fever

Lupus

Septicemia

Types of Seizures

Classification Frequency

Generalized Tonic-Clonic Seizures

Simple Partial Seizure

Complex Partial Seizures

Seizure Complications

Status Epilepticus Single seizure lasting > 30 minutes Repeated seizures without regaining

consciousness in between

Brain consumes 300-500% more glucose and oxygen

Neuronal death occurs with exhaustion

Seizure First Aid

Drug Therapy

Dilantin (phenytoin) Gingival hyperplasia, hirsutism

Tegretol (carbamazepine) No grapefruit juice

Phenobarbitol

Depakote (divalproex)

Zarontin (ethosuximide)

Klonopin (clonazepam)

Felbatol (felbamate) Aplastic anemia, liver toxicity

Nursing Interventions

Carefully observe and record

Safety during a seizureAirwayNo restraintsNothing in the mouth

Suction, ambu bag, oxygen at bedside

Multiple Sclerosis (MS)

MS Pathophysiology

Unknown trigger stimulates immune response -> inflammatory response

->myelin sheath damage -> scar/plaque formation -> nerve impulse interruption

Types of MS

Benign/stable

Relapsing-remitting

Relapsing-progressive

Chronic-progressive

Symptoms

Treatment

ACTH (adrenocorticotropic hormone)

Prednisone

Interferon drugsFlu-like symptoms, sensitivity to sun

Immunosuppresive drugs

Additional drugs for symptom control

Exercise

Healthy diet

Parkinson’s Disease

Symptoms

Gradual and insidious

Triad of PDTremorRigidityBradykinesia (Bradykinesia Video)

Can also have depression, anxiety, short-term memory probs

Sleep disorders

Treatment

Levodopa with carbidopa (Sinemet)Other drugs (reserve combo therapy for later in the disease)Physical and occupational therapySurgical management for relief of symptomsDiet

Nursing Care

Fall prevention Have them consciously think about stepping over an

imaginary line Drop rice kernels and step over them Rock from side to side Lift the toes when stepping Take one step backward and two steps forward Remove rugs Elevated toilet seat Slow-stretch-hold movements Wide base of support

Myasthenia Gravis (MG)

MG AssessmentPhysical Exam Progressive muscle

weakness Fatigue Speech difficulties Ocular palsies Ptosis Diplopia Respiratory distress Cough, gag reflexes

Diagnostic Tests EMG Tensilon test (pg

1513) Myasthenic crisis Cholinergic crisis

Treatment

Anticholinesterase drugs (Mestinon or pyridostigmine)

Alternate-day corticosteroids (prednisone)

Immunosuppressants (cyclosporine, Imuran)

Avoid many classes of drugs

Thymectomy

Plasmapheresis

Immunoglobulin G

Nursing Care

Distinguish between myasthenic crisis and cholinergic crisis

Semisolid foods

Schedule drugs so peak action is at mealtimes

Restless Legs Syndrome (RLS)

Idiopathic or secondary

Related to abnormal iron metabolism and problems with dopamine

Sx – paresthesias to severe pain to calves primarily when sedentary, sleep disturbance

Tx – treat underlying condition, parkinson drugs, antiseizure drugs

Amyotrophic Lateral Sclerosis (ALS)

Lou Gehrig’s disease

Rare, progressive disorder

Death from respiratory failure within 2-6 years

Sx – weakness of upper extremities, dysarthria, dysphagia

Tx – none

Remains cognitively aware while wasting away

Huntington’s Disease (HD)

Genetic disease with deficiency of Ach and GABA

Sx – chorea, worsening gait, risk for aspiration/malnutrition, cognitive deterioration, loss of speech

Need 4000-5000 calories per day

Death within 10-20 years, no cure

Xenaxine for chorea, haldol, valium, dopamine-depleting agents

Alzheimer’s Disease (AD)

Chronic, progressive, degenerative

Cause is unknown

Findings – amyloid plaques, neurofibrillary tangles, loss of connections between cells, cell deaths

Symptoms

Warning signs (pg 1524)

Subtle deterioration in memory (1st sign)

Loss of recent memory

Decrease in personal hygiene

Loss of concentration

Agitation, aggression

Significant cognitive impairments

Loss of long-term memory

Treatment

Cholinesterase inhibitors

Namenda (memantine)

Antidepressants

Antipsychotics

Nursing Care

Early recognition of the disease

Memory aids and cues

Give simple directions

Use distraction, rather than confrontation

Limit number of choices

Provide space for safe pacing

Provide boundaries (red tape)

Don’t ask why

Judicious use of restraints

Interventions for sundowning

Nursing Care

Fall prevention

Prevent wandering

Medic Alert bracelet

Nutrition – pureed food, thickened liquids, supplements

Good oral care

Infection prevention

Prevention of incontinence, constipation

Caregiver support

Dementia vs Delirium

Insidious onset

Symptoms progressive

Duration of months to years

Progressive impairment

Consistently poor performance in mental status testing

Caused by neurodegenerative conditions & vascular disorders

Rapid onset

Lucid intervals

Duration of hours to 1 month

Fluctuates in severity

Mental status testing improves when patient recovers

Caused by a interaction of their underlying condition with a precipitating event

Nursing CareDementia Delirium

Careful assessment (use Mini-Mental Status Exam – MMSE)

CT/MRI to look for vascular changes

Similar care as for AD

Recognition of high risk pts

Careful assessment (use Confusion Assessment Method – CAM tool)

Labs, CT/MRI only if injury suspected

Eliminate precipitating factors

Calm, safe environment

Personal contact

Eyeglasses, hearing aids

Drugs only for severe anxiety