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Adult Health Exam 2: Neurology

Terms in this set (77)

What is Huntington Disease (HD)?
Hereditary disorder transmitted as an autosomal dominant trait at the time of conception
Variations in disorder due to type of mutation
Both neurologic and behavior disorders starting age 30-40
Decrease in GABA and Ach
Leads to uninhibited motor activity
What is the implications of inheritance of Huntington Disease (HD) from the father?
Earlier onset and shorter life span
What is the implications of inheritance of Huntington Disease (HD) from the mother?
Longer life span
What is the onset of Huntington Disease (HD)?
Gradual
What are the symptoms of Huntington Disease (HD)?
Progressive mental status change (--> dementia) and choreiform movement (jerky movements)
What is stage 1 of Huntington Disease (HD)?
Onset of disease symptoms
Few extra movements, some neurologic changes (hallucinations, forgetfulness)
Over 0-5 years
What is stage 2 of Huntington Disease (HD)?
Increasing dependence
Over 5-10 years
Start losing function
What is stage 3 of Huntington Disease (HD)?
Loss of independence
After 15 years
What is the hallmark triad of Huntington Disease (HD)?
+ Family history (inherited)
Gradual clinical onset of progressive dementia
Choreiform movements in the limbs, trunk, and facial muscles
What is involved in the assessment for Huntington Disease (HD)?
Decreased attention span
Personality changes
Neuro assessment
Poor balance (risk for falls)
Hesitant/expressive speech (communication)
Impaired respiration
Bladder/bowel incontinence (infection/pressure ulcers)
What are interventions for Huntington Disease (HD)?
Genetic counseling (tested to see if gene mutation is present, up to pt or family member if they want to know)
Provide resources for nutrition (due to choreiform movements), activity (risk for falls, PT, HH), communication, speech pathologist (during 2nd stage, swallowing difficulties, lots of drooling)
What are the nursing diagnoses for Huntington Disease (HD)?
1. Impaired verbal communication
2. Imbalanced nutrition: less than (2nd priority)
3. Impaired physical mobility
4. Risk for aspiration (priority)
What is the drug therapy for Huntington Disease (HD)?
Antipsychotics: To calm pt
Antidepressants: Because it is a progressive disorder (coping)
Antianxiolytic: Fear of future
Tetrabenazine (Xenazine): Only FDA drug specifically for Huntington's disease
What is lumbosacral back pain?
Most common cause of injury in work environment
More common than cervical pain
Pain due to muscle strain or spasm, ligament strain
Causes difficulty moving
Causes of low back pain
What are the causes of lumbosacral back pain?
Herniated nucleus pulposus
Spondylolysis (defect in the vertebrae in the lower lumbar)
Spinal stenosis
What is herniated nucleus pulposus?
Bulging
Nuclear pulposus pushes on spinal cord causing pain
Level of pain depends where injury occurred
Numbness, pain, tingling, possible bowel and bladder problems (locations)
Usually around 40 years, men more common
What is spondylolysis?
Defect in the vertebrae in the lower lumbar
Slipped disk
Pain, numbness, radiates to buttocks and LEs
Effects mobility and ability to perform ADLs
Assess pulses, sensation, ROM
What is a herniated disc?
Presses on adjacent nerves
Most common between L4-5
Ask about history (more injury makes injury more common)
Spinal area weakens with age
What is the cause of a herniated disc?
Hyperflexion
Lifting heavy objects
What is involved in the assessment for a herniated disc?
Complaint of pain (may change due to swelling/blocking)
Look for appropriate vertebral alignment (look for bulging)
Pain may radiate to lower extremity
Muscle spasm
Assess pulses
Paresthesias (altered sensation, numbness, tingling)
Bowel/bladder control
Diagnosed by MRI or CT
Problems with ambulation (document)
Prevention
What are the interventions for a herniated disc?
Williams position
Semi-Fowler's with knees flexed to relax back muscles and relieve pressure on nerve
Raises disc up, relieving pressure
Exercise to strengthen lower back
Physical therapy as tolerated
No exercise until pain resolved
Heat/ice
Heat (hot bath/shower) increases blood flow, heals nerves
Ice can relieve pain
Pain meds
Firm mattress and flat position
What is nonsurgical management for herniated disc?
Positioning
Drug Therapy (muscle relaxants, NSAIDs, local steroid injections, nerve medicines)
Heat Therapy (help with blood flow)
Physical Therapy (help with mobility)
Weight Control (help relieve pressure)
What is drug therapy for herniated disc?
Muscle relaxants (Flexeril, Zanaflex)
NSAIDs (Naprosyn, Ibuprofen)
Local steroid injection
Chronic pain ➔ Neurontin, Trileptal
What are nursing diagnoses for herniated disc?
1. Acute pain (priority→ limits the pt)
2. Impaired physical mobility
Outcomes: Report reduced pain
What is PLDD?
Percutaneous Laser Disk Decompression
Performed in specialized centers
Local anesthetic used
Needle inserted under fluoroscopy
Laser removes herniated portion of disk
Clients usually immediately pain free
Usually 24 hours of bedrest (no quick, jerky movements)
Monitor for fluids expulsion from needle site
What is surgical management for herniated disc?
Less muscle injury
Decreased blood loss
Decreased post op pain
Patients go home the same day
Interbody cage fusion
Direct current stimulation
What is a diskectomy for herniated disc?
Surgically remove portion of disc causing compression
What is a laminectomy for herniated disc?
Removal of laminae causing compression
What is a spinal fusion for herniated disc?
Use if spine unstable, repeated laminectomies
Bone fragments removed from iliac crest of pelvis
Fragments grafted between disks to increase support
What is important during pre-op for herniated disc?
Obtain baseline assessments (pain, neurological)
What is important during post-op for herniated disc?
Assess pain, neurological status (ability to move extremities)
Prevent complications (Halo sign→ indicative of CSF leak; headache; bulging at incision; hematoma formation)
Assess vitals Q4h (fever, hypotension)
Perform neuro assessment at least Q4h
Check ability to void (8 hr after surgery)
OOB (out of bed)
Laminectomy - OOB evening of surgery
Fusion - OOB after 24 hours of bedrest or as ordered
Inspect surgical dressing (blood, CSF)
Lay pt flat and notify physician if CSF
Empty drainings
TCDB (log-roll)
SCDs until ambulatory
Avoid prolonged sitting/standing
Don't twist, push don't pull, straight back, lift with legs
Sleep on good mattress
No heels
What is Restless Legs Syndrome (RLS)?
Leg paresthesias
Irresistible urge to move
Possibly associated with nerve damage in legs or spinal cord (peripheral)
Family hx
Higher in DM2
Vitamin/mineral deficiencies, smoking, SSRIs
Burning or crawling sensation in legs
Symptoms usually worse in evening (night walkers)
What RLS treatment?
Limit caffeine, nicotine, and alcohol
Avoid strenuous activity 2-3 hrs prior to bedtime
Severe cases treated with anxiolytics and nerve impulse inhibitors
Walking, stretching, moderate exercise, warm bath
What is RLS drug therapy?
Sinemet
Dopamine agonists (Mirapex, Ropinirole)
Antiepileptics (Gabapentin, Carbamazepine)
Benzodiazepines
Opiates (if pain)
What is Trigeminal Neuralgia (TN)?
Also known as tic douloureux
Effects CN 5: trigeminal
Cause related to excessive firing of irritated fibers in nerve
Provoked by stimulation of trigger zone (unknown)
Unilateral (one-sided)
More in >50 yo, women
Facial pain in sudden, intense facial spasms
Bouts of pain for several weeks/month, then disappears
Older→ in between bouts become shorter
Priority→ pain management
Drug treatment first but may need surgery down the line
What is involved in TN assessment?
Unilateral face pain
Occurs in spasms
Excruciating, sharp, shooting, piercing, burning, stabbing pain
Can cause inability to talk, smile, eat, shave, wash face, brush teeth
What is involved in TN drug therapy?
Carbamazepine*, Gabapentin, Phenytoin, Baclofen: Reduce nerve stimulation (antiepileptics)
Fosphenytoin: Administered IV to stop sudden attack of severe nerve pain
Alcohol/phenol injection: Injected directly into trigeminal branch to relieve pain up to 16 months (numbs)
What is important about TN surgery?
If pt not responding to drugs
Can cause permanent numbness on affected side: Teach pt to be careful with affected side (eye, ear, nose, mouth-gums/teeth/chewing)
Psychosocial considerations (depression)
Counseling
Communication
Long term pain relief
Microvascular Decompression
Moving small artery off of trigeminal nerve
Sponge placed beneath artery to prevent compression/firing
Percutaneous stereotactic rhizotomy (PSR): Ambulatory care procedure
What is Bell's Palsy?
Acute paralysis of cranial nerve VII but may also affect: Cranial nerves V (trigeminal) and VIII (vestibulocochlear, auditory)
Acute onset
Caused by inflammatory process
What is involved in Bell's Palsy assessment?
Unilateral facial paralysis occurs within 48 hours to 5 days
Pain behind ear precedes episodes of paralysis
Drawing sensation present (on unaffected side)
Cannot close affected eye, wrinkle forehead, smile, whistle, or grimace
Taste is partially impaired
Possible tinnitis
Full recovery within weeks to months
15% to 20% exhibit residual weakness
What is Bell's Palsy drug therapy?
Prednisone within first week
Analgesics for pain
Antiviral drugs
Artificial tears for affected eye (cornea must be protected, must be manually close)
Neurontin
Psychosocial support
Unable to chew, may drool on affected side
Use unaffected side to eat and drink (frequent small meals, soft diet)
PT for facial exercises
Facial sling
Warm moist heat for circulation
What is TIA and Reversible Ischemic Neurologic Deficit?
Blood supply to any part of brain is blocked for a few minutes→ infarction
Brain metabolism and location determines symptoms
Swelling from stroke may affect other side of brain depending on location of stroke because of compression
"Warning sign" (TIA→ miniclots, minor symptoms that is temporary, no permanent damage, usually overlooked unless observed by someone else)
Transient focal neurologic dysfunction due to brief interruption in cerebral blood flow
What is a stroke?
Caused by a change in the normal blood supply to the brain.
National Stroke Association now uses the term "brain attack"
Any stroke is a medical emergency
Needs to be treated immediately to eliminate disabilities
What are the risk factors for a stroke?
HTN
Atherosclerosis
Hyperlipidemia
Diabetes mellitus
Cocaine use
Atrial fibrillation (clots)
Smoking
Use of oral contraceptives
Obesity
Hypercoagulability
Cerebral aneurysm (hemorrhagic stroke)
AV malformation (prone to aneurysm or stroke, genetic)
What are the two types of stroke?
Ischemic
Hemorrhagic
What are the most deadly hemorrhagic strokes?
Intracerebral or subarachnoid
What are the types of ischemic strokes?
Thrombotic
Embolic
What are the types of hemorrhagic strokes?
Aneurysm
Hypertension
AV malformation
What is an ischemic stroke?
Caused by occlusion of either thrombus or embolus
80% of all strokes are ischemic
Thrombotic
Embolic
Can lead to hemorrhagic stroke
Assess neuro (pupils)
What is an thrombotic stroke?
Caused by atherosclerosis of arteries (usually at bifurcation of common carotid and vertebral)
Onset slow and gradual (minutes to hours)
Risk factors include HTN, atherosclerosis: Smoking, alcohol use (high risk factors)
Neurologic deficits present during first few weeks with gradual progression to speech deficits and confusion
What is an embolic stroke?
Caused by group of clots that break off and travel to cerebral arteries
Risk factors include atrial fibrillation, ischemic heart disease, rheumatic heart disease, MI, smoking, alcohol use
Onset sudden
Complete, immediate neurologic deficit at onset
What is an hemorrhagic stroke?
Vessel integrity is interrupted and bleeding occurs into the brain tissue or into the spaces surrounding the brain (ventricular, subdural, and subarachnoid)
Life threatening emergency
What causes a hemorrhagic stroke?
Ruptured aneurysm (localized weakening and distortion of vessel wall)
Rupture of an arteriovenous malformation
Severe hypertension
What is involved in a cognitive stroke assessment?
Changes in LOC
Denial of illness
Spatial and proprioceptive dysfunction
Memory impairment
Decreased ability to concentrate
What is involved in a motor stroke assessment?
Paralysis/weakness on one side of body*
Hypotonia (flaccid paralysis)
Hypertonia
Facial droop*
What is involved in a sensory stroke assessment?
Cannot properly use an object
Cannot complete purposeful activities
Neglect syndrome (pays attention to only one side of body)*
Hemianopsia (blindness in half of visual field)
What is involved in a stroke assessment?
Must be evaluated within 10 mins
Extremely painful headache (hemorrhagic)
Priority→ ABCs
What is cranial nerve 5 involvement in a stroke?
Inability to chew
What is cranial nerve 9/10 involvement in a stroke?
Inability to swallow
What is cranial nerve 7 involvement in a stroke?
Facial paralysis
What is cranial nerve 9 involvement in a stroke?
Absent gag reflex
What is cranial nerve 12 involvement in a stroke?
Impaired tongue movement
What are symptoms of a right sided stroke?
Visual awareness (may be disoriented to time and place)
Impulsivity
Poor judgement (problems with spatial and proprioception)
Personality change (anger, aggression)
Speech impairment
What are symptoms of a left sided stroke?
Language issues (communication issues)
Mathematics
Analytical thinking
Aphasia
Dyslexia/alexia
Motor changes (right sided issues)
What are complications of a stroke?
Dysphagia
Aspiration (priority)
Unilateral neglect (do everything with the affected side first)
Ptosis (eyelid drooping), visual field deficits, or pallor and petechiae of the conjunctiva
Amaurosis fugax, a brief episode of blindness in one eye, results from retinal ischemia caused by ophthalmic or carotid artery insufficiency
Hemianopsia, or blindness in half of the visual field, results from damage to the optic tract or occipital lobe
What are lab values to monitor in a stroke?
PT/INR/PTT - establish baseline anticoagulant levels
Increased hct/hgb (ischemic)
Decreased hct/hgb (hemorrhagic)
What about a CT is important to monitor for a stroke?
Identify presence of ischemia/bleeding
Initially negative for ischemic strokes (constantly evolving)
24 hours later shows ischemia and edematous changes
What are nursing diagnoses for a stroke?
Ineffective tissue perfusion (cerebral)
Impaired physical mobility and self care deficit
Disturbed sensory perception
Unilateral neglect
Impaired verbal communication
Impaired swallowing
What are nursing interventions for a stroke in regards to ICP?
Monitor patients for signs of increased ICP
First sign = declining LOC*
Restless, irritable, confused, headache, N/V, slurred speech, pupil change
Assess q2hr
What are signs of increased ICP?
Elevate HOB to 30 degrees
Maintain head in midline position
Avoid clustering activities
Maintain quiet environment
Decrease lighting
What are nursing interventions for a stroke in regards to communication?
Provide repetitive directions to complete task
Break down tasks into manageable parts
Face client and speak slowly, clearly
Repeat names of objects used on routine basis (toothbrush, comb, underwear)
Use picture or communication board
What are nursing interventions for a stroke in regards to swallowing safety?
Assess swallowing, gag reflex, mouth for drooping/drooling
Position sitting in chair or straight up in bed
Use soft or semi-solid foods, thicken liquids
Monitor weight
Use dietary supplements as necessary to provide adequate nutrition
Place food in back of mouth to prevent trapping in cheek
Locate environment free of distraction so client can concentrate
Observe for swallowing fatigue
What is surgical intervention for a stroke?
Carotid endarterectomy (increase blood flow to brain)
Extracranial-intracranial bypass (bypass the clot to increase circulation)
What is drug therapy for a stroke?
Thrombolytic Therapy
Anticoagulant Therapy
What is thrombolytic therapy for a stroke?
Can be systemic or catheter-directed
Recombinant tissue plasminogen activator (Retavase)
For acute ischemic stroke
Must be given within 3 hours of onset of symptoms
Activates plasminogen ➔ breaks down fibrin ➔ dissolves thrombus
Many contraindications (stroke, head bleed, hemorrhage, elevated PTT, MI, anticoagulant therapy, pregnancy)
What is anticoagulant therapy for a stroke?
ASA, heparin, Lovenox, warfarin
If thrombolytic therapy received, client usually receives anticoagulant therapy (follow up, not simultaneous)
Heparin IV/SQ to prevent further strokes, prevent DVT
PT, PTT values monitored during therapy
Therapeutic levels are 1.5 to 2 times client's baseline
Target INR ➔ 2-3; if cardiac clot origin ➔ 3-4.5
Daily aspirin (should not be given for 24 hr after thrombolytic)
What is rehabilitation for a stroke?
Require continued nursing care
Need extensive physical, occupational, recreational, speech-language, cognitive
Medication schedules, ambulation/transfer skills, communication skills, safety precautions, dietary management, activity levels, self-care skills
Family members taught how to use any equipment
Encourage family to spend time away from client to prevent overexertion and to get rest themselves
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