neuromuscular assessment for skills quiz 2

ischemic stroke

an artery in the brain narrows or becomes blocked, preventing blood flow. caused by thrombus or embolus → brain tissue dies

thrombus

blood clot (forming in an unhealthy artery in the brain) → lack of blood flow to the tissue the artery supplies → ischemic stroke

embolus

a blood clot that forms elsewhere in the body and travels to an artery in the brain → lodges in a narrow artery obstructing blood flow → ischemic stroke

hemorrhagic stroke

abnormal bleeding interrupts normal blood flow (ie, blood vessel bursts) → spills blood directly onto brain & robbing intended tissue of nourishment → destroy brain tissue

subarachnoid hemorrhagic stroke

weak spot in blood vessel wall (aneurysm) bursts → leaking blood into subarachnoid space btwn brain and skull → high pressure bleeding results in dmg to brain tissue

• WORST HEADACHE OF YOUR LIFE

ischemic stroke treatment

medication to break up the clot causing stroke (TPA given within 3-4.5 hrs after symptom onset), or surgery to pull the clot out

hemorrhagic stroke treatment

surgery to clip the burst blood vessel in brain, or reduce the pressure of the blood on your brain (DONT GIVE TPA BC THEY ARE ALREADY BLEEDING A LOT)

• coil method through the femoral artery to prevent aneurysm from bursting

monro-kellie hypothesis (video key notes)

• brain takes up most of the room in the skull

• cerebrospinal fluid (CSF) protects the brain by acting as a buffer around it

• blood = transport of fluid, oxygen, and nutrients

• intracranial pressure (ICP) = pressure inside skull, normally 5-15 mmHg. any increase volume of the brain, blood, or csf → increased pressure

• increased ICP → some of the blood is pushed down into the body by pressure, as compensation for the brain and CSF to have space to expand into

• ICP >20 mmHg is dangerously high → brain cells are squashed and damaged bc of the limited area in the skull → too much pressure on brain stem = death

• drain can be inserted into ventricles to drain CSF → reducing volume and pressure inside skull (hopefully back to safe limits)

focused neuro assessment: for stroke, seizure, decreased LOC, and headaches

• LOC/GCS (for sleepy PTs)

• follows commands

• vision (look straight, and then peripheral)

• PERRLA (are the pupils equal, round, reactive to light, and accommodating)

  • look at a far away object and bring the object closer to their eyes = accommodating

• eye movement - follow pen from left to right

• extremities - grip strength, and gas pedal + dorsiflexion

• speech - expressive aphasia? slurring?

• facial symmetry - show me your teeth

• sensation - take smth pointy and poke them on left and right side of face, arms, leg (under gown, on skin)

• headache PQRST

  • provoking factors, quality (stabbing, aching, throbbing), region/ radiation, severity 1-10, timing (when did it start, does anything make it better or worse)

• stiff neck (nuchal rigidity)

  • if they have this and headache = brain stem squashed

• dysphagia = trouble swallowing

labs, diagnostics, and interventions for neuro assessment

• labs: check blood glucose, arterial blood gases (ABG - is it high co2 leading to unconsciousness?)

• diagnostics: CT scan, MRI

• interventions:

  • low sugar = hypoglycemic protocol

  • overdose = narcan or flumazenil (think about when the last narcotic or sedative was given)

  • high CO2 → give bipap machine

reality tips for neuro assesssment

• for decreased LOC, check when the last narc or sedative was given

• if not waking up, stimulate PT with touch gently. → sternal rub and/or pinch the finger and toe nails to produce noxious stimuli

• if new or worsening stroke occurs, call code stroke → labs and stat CT ordered → administer TPA (Alteplase) w/i 3-4.5 hrs of ischemic stroke symptom onset

glascow coma scale components

• eye opening

• motor response

• verbal response

glascow coma scale components - eyes

• eye opening

  • 4 = spontaneous eye opening

  • 3 = opens eyes to speech

  • 2 = eyes open to pain (light touch, if no response → noxious stimuli such as pinching fingernails or sternal rub, or pinch their trapezius muscle)

  • 1 = no eye opening

glascow coma scale components - motor response

• motor response

  • 6 = obeys commands fully

  • 5 = localizes to noxious stimuli (trying to remove the stimulus)

  • 4 = withdraws from noxious stimuli (pulling away from you)

  • 3 = abnormal flexion (decorticate posturing; flexes elbows and wrists while extending lower legs to pain) = “towards the core”

  • 2 = abnormal extensor response (decerebrate posturing; extends upper and lower extremities to pain) “celebrating penguin”

  • 1 = no motor response

glascow coma scale components - verbal response

• verbal response

  • 5 = alert and oriented

  • 4 = confused yet coherent speech

  • 3 = inappropriate words and jumbled phrases consisting of words

  • 2 = incomprehensible sounds

  • 1 = no verbal response

FAST quick neurological assessment

• face

  • ask the person to show their teeth and inspect for drooping or asymmetry

• arms

  • ask the person to raise both arms - does one drift downward

• speech

  • ask the person to repeat a simple phrase. is their speech strange or slurred

• time

  • if you observe any of these signs, call 911 immediately and also note the time that you observed the symptoms

neuromuscular interventions

• blood glucose low = give glucose

• if co2 elevated = bipap (helps ppl breath and release co2)

• if suspected OD = narcan or flumazenil

• seizure = monitor/protect airway - turn on side & time it + PRN ativan antiseizure med

neuromuscular diagnostics

• CT scan of the brain with and/or without contrast

  • ischemic example: there is black/dark large spot on the imaging of ischemic stroke bc no o2 to tissue → tissue necrosis (the black thing is necrosis)

  • hemorrhagic example: white spot on imaging = brain bleeding (don’t give TPA here)

• MRI of the brain

• (side note - CT is better for quick emergencies & for imaging of bones, chest, and trauma; but MRI offers superior detail of soft tissue)

• EEG - related to seizures

  • watches electrical activity, firing in brain (ex: for absent seizures where there is no convulsing but misfiring in brain is present)

joey’s seizure first aid video key notes

• pad the PT on the side rails and under their head to prevent injury

• take note of the time of occurrence, and how long the seizing lasts

• loosen clothing

• don’t hold down, dont put anything in their mouth

• turn to side in case of vomit to protect airway

• administer PRN ativan or call DR and ask for anticonvulsant med

• check for airway patency after seizure stops

cranial nerves (know the nerve and function; number is not necessary)

• I = olfactory - sense of smell

• II = optic - sense of vision

• III = oculomotor - pupil constriction (test pupillary reaction to light and ability to open and close eyelids)

• IV = trochlear - downward, inward eye movement

• V = trigeminal - jaw movements (chewing) and sensation on the face and neck

• VI = abducens - lateral movement of the eyes

• VII = facial - muscles of the face and sense of taste on the anterior 2/3rds of the tongue

• VIII = acoustic (vestibulocochlear) - sense of hearing

• IX = glossopharyngeal - pharyngeal movement and swallowing; sense of taste on the posterior 1/3 of tongue

• X = vagus - swallowing and speaking

• XI = accessory - movement of shoulder muscles

• XII = hypoglossal - movement of the tongue, strength of the tongue