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Neuro Assessment Megan McClintock, MS, RN 10/27/11.
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Transcript of Neuro Assessment Megan McClintock, MS, RN 10/27/11.
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