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2455 - Medsurg3 - Neuro (Exam 2)

Terms in this set (77)

Cranial Nerve 1
- Smell
- Assess with soap or coffee
- Head trauma or tumor
Cranial Nerve 2
- Behind the eyes
- Central & Peripheral Vision
- Stroke, Homonymous Hemianopsia, Pituitary tumors
Cranial Nerve 3
- Pupillary restriction
- PERRL
- Raise eyebrows, Eyelid droop
- Stroke, Trauma, Tumor
Cranial Nerve 4
- Cardinal gazes
- Look at nose
- Stroke, Trauma, Tumor
Cranial Nerve 5
- Trigeminal nerve
- Optic, Maxillary, Mandibular branch
- Use dull object to test sensation
- Trigeminal Neuralgia, Tumor, Trauma, Facial pain
Cranial Nerve 6
- Extra Occular movements (sideways)
- Observe for Nystagmus & Twitching
- Stroke, Trauma, Tumor
Cranial Nerve 7
- Facial Movement / Facial drooping
- Smile, blow out candle, wrinkle forehead, check nasal-labial fold, check for symmetry
- Bells palsy, Shingles
Cranial Nerve 8
- Acoustic nerve / Hearing
- Rub fingers together by each ear
- Meniere's
Cranial Nerve 9 & 10
- Swallowing & Gag reflex
- Stick out tongue & say AH
- Stroke, ALS, MS, Gullian barre
Cranial Nerve 11
- Spinal accessory
- Shrug shoulders, check resistance
- Keep stroke pt body in alignment
- ALS, Guillian Barre
Cranial Nerve 12
- Tongue movements
- Ask pt to stick out tongue. It should be midline. Look for problems eating, swallowing or speaking
- Stroke, ALS, MS, Polio
Multiple Sclerosis (MS)
- Myelin Sheath is damaged and can not regenerate causing a inflammatory response
- Autoimmune or Genetic
Multiple Sclerosis - Early Manifestations
- Eye problems: Blurred, Double, Nystagmus, Drooping eyelids
- Stumbling gait
- Trigeminal Neuralgia: Pain in face, prob swallowing
Multiple Sclerosis - Later Manifestations
- Fatigue / stiff muscles
- Muscle spasms / Hyperactive DTR
- Intention tremor, Vertigo
- Hearing loss, slow speech, 1/2 field vision loss
- ↓ Bladder/Bowel, Paresthsia
- ↓ concentration & short term memory
- Depression / Euphoria, Anxiety
MS - Remission Drugs
- Steroid or Immunosupressive therapy
- Methotrexate (Chemo)
- Cyclosporine, T-cell peptides, IVIg
- Mitoxantrone (Novantrone)
- Azathiopirine (Imuran)
- Natalizumab/Tysabri (BRMs)
Mitoxantrone (Novatrone) S/E
- Last resort / End stage
- Dysrhythmias, CHF, Crackles
- 2° Cancers
Natalizumab / Tysabri (BRMs) S/E
- Liver problems
- ↓ CBC
- Cardiovascular effects
MS - ↓ Flair up Drugs
Interferon Beta (BRM):
- Betaseron / Avonex / Rebif
S/E: ↑ BS, Flu like sx,

Glatiramer Acetate:
- Copaxone
S/E: Chest tightness, MI sx
FAST - Stroke
F: Facial drooping (Nasal folds)
A: Arm weakness
S: Slurred speech
T: Time-call 911 asap (3-4hrs)
Stroke - Pathophysiology
- Ischemia in brain tissue = hypoxia/hypogycemia = brain dysfunction (death of neurons)

- Opposite side of hemisphere affected (either motor or sensory)
Thrombolic Stroke
- Ischemic (Occlusive) Clot
- More than 1/2 off strokes
- Associated with atherosclerosis
- Slow onset
Embolic Stroke
- Ischemic (Occlusive) Dislodged Clot
-Emboli travels to cerebral arteries via carotid artery
- Sources of emboli are cardiac (AFib)
- Sudden onset
Hemorrhagic Stroke
- Aneurysm in the brain
- Usually younger pts
- Can be caused by HTN or Cocaine
Stroke Risk Factors
- HTN, DM, Heart Disease, AFib
- Smoking, Substance Abuse
- Obesity, Sedentary lifestyle
- Sleep apnea, ↑ Lipids, ↑ Homocystein
- Hereditary hypercoagulation
Neglect Syndrome
- Treating affected side like it is not there
- Usually with right cerebral hemorrhage
Assessment Findings - Right Cerebral Hemisphere Stroke
- Unaware of deficits
- Impaired proprioception
- Disoriented to time/place
- Impulsivity/poor judgement
Assessment Findings - Left Cerebral Hemisphere Stroke
- Aphasia (Can't speak)
- Alexia (Can't read words)
- Agraphia (Can't write)
- Difficulty with math
- Slow & Cautious
- Quick anger & frustration
Assessment Findings - Temporal Lobe Stroke
- Wernicke's or Sensory (Receptive Aphasia)
- Unable to understand spoken & written words
- Neologisms (learn what made up words mean)
- Use swear words when didn't before
- Memory loss
Assessment Findings - Frontal Lobe Stroke
- Broca's or Motor (Expressive Aphasia)
- Motor speech problems (Point to pictures)
- Understands but unable to communicate
- Difficulty with writing
- Frustration & anger / Personality changes
TIA
- Transient Ischemic Attack (Silent Stroke)
- Last minutes - 24hrs
- Sx resolve in 30-60min / No deficits
- Pt on Plavix after
RIND
- Reversible Ischemic Neurologic Deficit
- Warning sign for stroke
- Lasts 24hrs - 1 week
Homonymous Hemianopsia
- Left side of vision on each eye not there
Meds for Stroke Pt
- Thrombolytic Therapy (3-4hrs)
- Revasculization
- Anticoagulants or Antiplatelets
- Antiseizure meds
- Calcium channel blockers
- Antidepressants / Antianxiety / Analgesics
- Intracranial Pressure Monitoring
Nursing Care for Pt with a Stroke
- Turn Q2hrs, Proper body alignment
- Lay flat or Semi-Fowlers, SCDs
- Get out of bed on unaffected side
- Swallow eval, Speech eval, PT, OT
- Straight cath, Stool softners
- Don't get frustrated
Parkinson's Disease
- Neurodegenerative disease of the midbrain nerves
- ↓ Dopamine
Parkinson's 3 Cardinal Symptoms
- Bradykinesia (Slowing of movement)
- Tremor (Pill rolling)
- Muscle rigidity (Not flexible)

Cogwheel (rhythmic), Plastic (move but resistance), Lead pipe (No movement)
Parkinson's Assessment Findings
- Fatigue, Masklike facial expressions
- ↑ sweating, fixed eyes, drooling
- prob speaking, echolalia
- small handwriting, prob picking up objects
- GI rigidity, prob swallowing
- Easily upset, mood swings, paranoia
Post Encephalitic Parkinsonism
Drug induced Parkinson's or caused by toxins
Anticholinergics - Parkinson's Med
- ↓ Stimulation / Improve balance between excitatory & inhibitory
- Helps rigidity & tremors

S/E: Confusion, Dry mouth, Constipation, Urinary retention

Cogentin / Artane
Antihistamines - Parkinson's Med
- For slight tremors

S/E: ↑ BP & ↑ BS

Benedryl
Dopaminergics - Parkinson's Med
- For marked rigidity & tremors
- Better balance of dopamine & acetocholine

S/E: OH, Dyskinesia, Hallucinations

Levodopa-Carbidopa (Carbidopa blocks conversion of Levodopa)
Dopamine Agonists - Parkinson's Med
- Bind to dopamine & stimulate extra pyramidal tracks

S/E: Nausea, Hypotension, Fatigue

Mirapex, Requip
COMT Inhibitors - Parkinson's Med
- ↑ availability of Levodopa
- Give w/ Dopaminergics

S/E: Vivid dreams, Dyskinesias, Quick liver failure

Entacapone
MAO Inhibitors - Parkinson's Med
- Prevents cell death of substania nigra
- Used in begining

S/E: No Tyramine, No wine, beer, cheese, aged meats, chocolates
Teaching Interventions for Parkinson's Pts
- Speak slow & clear / No buttons
- Lay on stomach w/ head to side
- Soft foods, weighted spoons
- Avoid concentrating on feet when walking
- Use a rocking motion to get up
- Take a drug holiday
ALS - Lou Gehrig's Disease
- ↑ & ↓ motor neuron disease
- Cognitive but frozen
- No cure / Quick time frame
- Usually ↑ extremities 1st
ALS - Lou Gehrig's Disease S/S
- Progressive weakness
- Muscle wasting
- Spasticity then paralysis
- Dysphagia / Nasal quality to speech
- Fatigue while talking, facial twitching
- Eventually lose respiratory control
ALS - Lou Gehrig's Disease Teaching
- Rilutek (Riluzole)- Not cure but extends survival time
- Soft foods pt can swallow / May need tube feedings
- May need BiPAP or mechanical vent
- Pt needs advance directive / Emotional support
Myasthenia Gravis (MG)
- Chronic neuromuscular autoimmune disease
- Weakness in cranial nerves & respiratory
- Can't excite muscles so it can't contract
Myasthenia Gravis (MG) S/S
- Rapid onset of fatigue
- Muscle weakness
- Incomplete eye closure, ↓ extraocular movement
- Droopy eyelid, Double vision
- Prob swallowing / chewing
- Respiratory difficulty
- Weakness of voice
Myasthenia Gravis (MG) Interventions
- Cholinesterase Inhibitors / Anticholinesterases
- Give meds when pt wakes up w/ food
- Respiratory support, Assist ADLs
- Eye protection, Nutritional support
- Communicate when pt at peak level
- Family needs to know CPR
Myasthenia Gravis Crisis
- Exacerbation of sx
- ↑ BP, ↑HR, ↑Resp, Anoxia, Cyanosis
- Incontinence, ↓ UO, Absent cough & swallow reflex
- Pt didn't take meds or dose to ↓

Tx: Give meds
Cholinergic Crisis
- Exacerbation of muscle weakness
- ↓ BP, NVD, Abd cramps, Pallor, Facial twitching, Constricted pupils, Blurred vision
- Pt over medicated, infection, dehydrated (Mestinon / Regonaol / Cold meds)

Tx: Atropine, Enemas, Laxatives
Mixed Crisis
- Apprehension, Restlessness, Dyspnea, Dysphagia, Dysarthria, ↑ tears & saliva, Diaphoresis, Weakness
- Watch Respiratory
- Can happen when trying to fix a crisis
Tx: Explain what's going on, ↓ anxiety, ↑ or ↓ meds see what works
Guillain-Barre Syndrome (GBS)
- Acute inflammatory process
- Affects peripheral nervous system myelin: Can regenerate
- Motor weakness & paralysis
- Hx of Illness, Trauma, Surgery, Vaccines, EBV, ↑ Resp infection, Stomach bacteria (1-3wks prior)
Guillain-Barre Syndrome S/S
- Abrupt muscle weakness & pain
- Know what's going on but can't move
- Ascending or Descending
- Cranial nerves involved
Ascending GBS
- Weakness/Paralysis begins in ↓ extremities and moves ↑
- 50% pts have Respiratory compromise
- Intubate if you see creeping up (O2 won't work)
- Most common
Descending GBS
- Weakness progresses & affects Respiratory Function & ↓
- Visual disturbances, Eye muscle paralysis, DTR ↓
- CN 7,9,10,11
- Can't eat, dysrthymias, ↓HR
- NG Tube, TPN, Intubate
Priorities for GBS pt
- Respiratory function
- Proper body alignment / ROM
- Pain management (Opiates)
- ↓ Anxiety, talk to pt, they will recover
- Manage cardiac dysfunction
- IVIg therapy / Plasmapheresis
- 6mo - 2yrs myelin regenerated
Assessment after Back Surgery
- Neuro checks, VS, Numbness & tingling
- Able to void, Bladder/Bowel control
- Pain Control (PCA 24hr then Oral 24hr)
- Wound care (MD removes 1st dressing)
- Swallowing ability
- CSF check
- Log roll, no bending or twisting, Use assistive devices
Spinal Shock
- Immediately after injury
- Cord is bleeding & compressing
- Flaccid paralysis
- Loss of activity ↓ lesion
- ↓HR, ↓BP, paralytic ileus
What indicates Spinal Shock is Resolving?
- Return of reflex activities

- Lasts few days to several months
Autonomic Dysreflexia
- Injuries ↑ T6, after spinal shock
- Cerebral cortex no longer controls SNS because of blocked impulse transmission (Epinephrine d/c)
- ↑BP, ↓HR, Flushing above lesion, Severe HA, Nasal stuffiness, Sweating, Nausea, Blurred vision
Priority Interventions for Autonomic Dysreflexia
- Sit them upright to ↓ BP
- Give meds (antihypertensives, Catepres)
- Caused by full bladder, BM, pants to tight, wrong position, sitting to long
- Life Threatening
Anterior Cord Syndrome
- Damage to anterior of gray & white matter (Chest down / not arms)
- Motor, pain & temperature sensation lost ↓ injury
- Touch, position & vibration intact
- Small % recover some functional motor control
Posterior Cord Lesion
- Damage to posterior gray & white matter (Waist ↓)
- Motor function intact
- Loss of vibratory sense, crude touch, position sense
Brown-Sequard Syndrome
- Penetrating injury that hemisection of spinal cord or 1/2 spinal cord
- Loss of pain, temp, & light touch on opposite side
- Loss of motor function & vibration, position, & deep touch sensation on same side as cord injury
Central Cord Syndrome
- Lesions of the central portion (waist ↑)
- Loss of motor function is more severe in ↑ extremities than ↓
- Varying degrees & patterns of sensation remain intact
Lumbosacral Injuries
- Damage to Cauda Equina or Conus Medullaris
- Variable pattern of motor or sensory loss
- Peripheral nerves have potential for recovery & regrowth
- Neurogenic bowel & bladder
Assessment findings of Proprioception (Position sense) of the lower extremities
- Move toes ↑ & ↓ & pt identify position of toes, have pt wiggle toes, flex & extend feet & knees & move 1 or both hips
- L2-4: Apply resistance w/ pt lifting legs
- L5: Apply resistance w/ pt dorsiflexing feet
- S1: Apply resistance w/ pt plantar flexing feet
Spinal Cord Injury Meds
- Solu-Medrol: ↓ inflammation, monitor infection, ↑BS, stress ulcers
- Fluids: ↑ blood flow to spinal cord & prevent/tx ↓BP
- Atropine: Tx ↓HR
- Dopamine: ↑BP & HR, helps kidneys
- Baclofen: to relax muscles
Spinal Cord Tumors
- Sxs depend on location
- Pain r/t compression, infiltration of spinal tracts or irrigation of spinal roots
- Assess weakness, spasticity, ↑ DTR, Ataxia, + babinski
- Surgery to remove tumor, decompression, cordectomy
Spinal Cord Injury Complications
C2: Intubated w/ vent
C3-5: ↓ diaphragm control, ↑ risk of arrest
C6-8: Sensory changes in hands & fingers
T7-9: ↑ Abdomen
T10: ↓ Abdomen, Umbilicus
L3-5: Sensation on top of foot & calf
S3: urinary sphincter control, foot drop
Trigeminal Neuralgia
- Chronic irritation of CN5
- Sudden, intense facial pain & spasms
- Unilateral, usually 2nd & 3rd branch
- Bouts of pain for weeks-months then spontaneous remission for days-years
Treatments of Trigeminal Neuralgia - Meds & S/E
Pain management w/
- Antiepileptics: Tegretol & Neurontin Ataxia (NV, dizziness, Fatigue, No ETOH)
- Muscle Relaxants: Baclofen (Dizziness, drowsiness, Confusion, Nausea)
- Lidocaine spray
Treatments of Trigeminal Neuralgia - Surgery & Complications
- Percutaneous stereotactic rhizotomy (puncturing the carotid artery)
- Microvascular decompression (Meningitis, CSF leak, Ataxia, Hearing loss, CN7 damage)
- Both: Facial numbness, weakness, reoccurrence of pain
Bell's Palsy
- Peripheral facial paralysis
- Motor aspects of CN7 (Unilateral)
- Upward movement of eyeball
- Drooping of mouth
- Flattening of nasolabial fold
- Cannot close eye
- Caused by inflammatory process triggered by HSV-1
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