ADVANCED-MS (Neurological dysfunction)

central nervous sytem vs. peripheral nervous system:

CNS--> brain and spinal cord

PNS--> contains autonomic (fight or flight/rest and digest) and somatic NS

neurological assessment includes:

assessment of pain, seizures, dizziness, weakness, visual disturbances, abnormal sensations, vitals, reflexes/posturing, cranial nerves, and cognition (ALOC)

Glasgow Coma Scale:

tests eye opening, verbal response, and motor response

(highest score you can get is 15, lowest is 3)

Eye Opening Response (GCS) (highest score is 4)

4-Spontaneous opening (awake/alert)

3- Opens to verbal command/speech

2- Opens to painful stimuli

1- Does not open eyes

Verbal Response (GCS) (highest score is 5)

5 - oriented

4 - confused

3 - inappropriate words

2 - incomprehensible sounds

1 - none

Motor response (GCS) (highest score is 6)

6-obeys commands

5-localizes pain

4-withdraws from pain

3-abnormal flexion

2-abnormal extension

1-none

Diagnostic tests for neurological problems/disorders:

-CT (quickest)

(if need contrast, assess for shellfish/iodine allergies)

-MRI

-Cerebral angiography

-lumbar puncture (NOT for patients with ICP)

akinetic mutism

unresponsiveness to the environment; the patient makes no movement or sound but sometimes opens the eyes

Locked-in syndrome

inability to move or respond except for eye movements due to a lesion affecting the pons

Increased Intracranial Pressure (ICP)

WHAT: An increase in pressure within the skull due to swelling, bleeding, tumor, or excess cerebrospinal fluid (CSF)

S/S:

Early signs--> SUBTLE changes in LOC first (restlessness, confusion, lethargy), blurry vision, slight increase in BP, irregular respirations, headache

Late signs--> coma, decorticate/decerebrate posturing, unequal/dilate pupils, and

CUSHING'S TRIAD (wide pulse pressure, bradycardia, and hypertension) with irregular respirations

Nurisng interventions for ICP:

-maintain airway/oxygenation

-keep neck midline (no flexion or rotation)

-reduce stimuli (limit suctioning, avoid straining/coughing/sneezing) + keep environment quiet and calm

-monitor ICP, pupils, and vital signs

-avoid fluid overload (can increase cerebral edema)

-meds: to prevent seizures--> phenytoin, to reduce swelling--> corticosteroids, or mannitol

(I- immobilize head, C- CO2; hyperventilate to lower carbon dioxide--> lowers ICP, P- position pt. 30 degrees or higher)

cerebral perfusion is closely linked to ICP. True or false?

true

MAP-ICP= cerebral perfusion pressure

normal ICP range

5-10

normal cerebral perfusion pressure (CPP) range

60-80

if a patient's CPP is less than 50, what does that indicate?

permanent neurological damage

(it should normally be between 60-80)

how can you maintain a patient's cerebral perfusion?

-control ICP/decrease pressure

-assess vitals/neuro. status every 15 minutes

-avoid extreme head rotation

-keep HOB flat or only 30 degrees

-monitor for hypoxia or hypercapnia (slight changes can affect CPP)

Decorticate posturing

arms flexed inward and bent in toward the body and the legs are extended

Decerebrate posturing

position of an unconscious person where the upper extremities and lower extremities are extended and the wrists are flexed (more severe neurological damage than decorticate)

dementia is a normal part of aging. True or false?

false, dementia is not normal

(assess mental status carefully to distinguish the difference between delirium and dementia)

cranial nerve 1

Olfactory (smell)

Assessment: Ask the patient to close their eyes and identify familiar smells (e.g., coffee, vanilla) in each nostril separately

cranial nerve 2 (II)

Optic (vision)

Assessment: Use Snellen chart

cranial nerve 3 (III)

Oculomotor (eye movement)

Assessment: PEARLA

cranial nerve 4 (IV)

Trochlear (eye movement)

Assessment: Ask the patient to look down and in

cranial nerve 5 (V)

Trigeminal

Assessment: Light touch, pain, temperature on forehead, cheeks, jaw

cranial nerve 6 (VI)

Abducens (motor)

Assessment: Ask patient to look laterally (side to side)

Cranial Nerve 7 (VII)

Facial

Assessment: Ask patient to smile, frown, puff cheeks, raise eyebrows, close eyes tightly

cranial nerve 8 (VIII)

Vestibulocochlear (hearing and balance)

Assessment:

-->Hearing: Whisper test, tuning fork (Rinne and Weber tests)

-->Balance: Observe gait, Romberg test (standing with eyes closed, feet together)

Cranial Nerve 9 (IX)

Glossopharyngeal

Assessment: test swallowing ability/gag reflex and taste

Cranial Nerve 10 (X)

Vagus

Assessment: Ask patient to say "ah" and watch uvula for midline elevation

Cranial Nerve 11 (XI)

accessory

Assessment: Ask patient to shrug shoulders against resistance and to turn head against resistance

Cranial Nerve 12 (XII)

Hypoglossal (tongue movement)

Assessment: Ask patient to stick out tongue (should be midline) and move tongue side to side

GCS of less than 8, ______

intubate

(always notify HCP immediately if GCS decreases)

upper motor neuron lesions can cause:

-loss of voluntary control

-increased mm tone

-mm spasticity

-no mm atrophy

-hyperactive and abnormal reflexes

lower motor neuron lesions can cause:

-loss of voluntary control

-decreased mm tone

-flaccid mm paralysis

-muscle atrophy

-absent/decreased reflexes

gerontological considerations when assessing neurological function:

-dementia is not a normal part of aging

-there is a reduction in muscle bulk

-decreased strength and agility but localized weakness is abnormal

-tactile sensation is dulled in older adults

-lack of temperature regulation

-memory, judgement, and language remain intact in the normal aging process (delirium is sign of acute symptoms)

always assess kidney function before a patient goes to CT with contrast. Why?

because the contrast material is cleared through the kidneys, so you want to have proper kidney function beforehand

what is a lumbar puncture used for?

to obtain CSF for examination

(CSF should be clear and colorless--> pink could indicate subarachnoid hemorrhage)