Neuro NURM-103 Exam Review

Why are both sides of the body assessed?

Asymmetry can indicate neuro issues

Why should MG pts NOT cluster activities?

Weakness worsens with repetitive use!

• Should be taking frequent breaks

Complete neuro assessment includes…

• Hx

• Mental status/LOC

• Pupil assessment

• Motor + sensory function

• Reflexes

Significant Neuro Hx examples

• Headaches/dizziness/vertigo

• Seizures

• Recent injuries/falls

• Weakness/numbness/tingling

• Difficulty swallowing/speaking

• Changes in coordination/balancing

Levels of Consciousness

• Alert

• Lethargic

• Stuporous

• Comatose

Memory assessment

Includes both short and long-term

• What did you have for breakfast?

• Where were you born?

CN I

Olfactory

CN II

Optic

CN III

Oculomotor

CN IV

Trochlear

CN V

Trigeminal

CN VI

Abducens

CN VII

Facial

CN VIII

Acoustic/Auditory

CN IX

Glossopharyngeal

CN X

Vagus

CN XI

Accessory

CN XII

Hypoglossal

Motor Function Assessment

• Tremors/Involuntary movements

• Muscle strength

• Cerebellar/Motor or Brainstem Integrity

What is assessed for cerebellar/brainstem integrity?

Gait and coordination

What is being assessed in gait?

Steady vs. unsteady

Coordination assessment

Finger to nose, our finger, and repeat

How are deep tendon reflexes graded?

0-4+

What is a normal deep tendon reflex grade?

2+ (nothing above or below)

What do hyperactive reflexes indicate?

Issue with upper motor neurons (brain/cord)

What is the light touch test?

Pt eyes closed → Touch with cotton ball and say “now” when they feel it

• FIRST sensory test

How is proprioception tested?

Pt eyes closed → Move finger/toe up and down and ask which way it was moved

Romberg test

Eyes closed and feet together

• Some swaying is normal

• Balance loss is not

What is Guillain-Barré syndrome?

Progressive paralysis beginning at lower extremity

Guillain-Barré Syndrome Risk Factors

• Possible autoimmune disease

• 20-50 y/o

• Swine flu shots

• May follow respiratory/intestinal infection

What should GBS patients NOT receive?

Flu shot

What does the immune system attack in GBS and how?

PNS via demyelination

What does demyelination cause?

Slowed/stopped nerve signals → Muscle weakness + other symptoms

What is the main trigger for Guillain-Barré syndrome?

Mild respiratory/GI infection

Guillain-Barré syndrome S/S

• Ascending paralysis

• “Pins and needles”/extremity numbness

• Dysrhythmias/unstable BP

• NO MUSCLE ATROPHY

Hx assessment for GBS

• Immune disorders?

• Diabetic?

• Recent accident?

• How long has numbness been happening?

• Recent GI/Resp infection?

GBS is short for…

Guillain-Barré syndrome

Priority GBS assessment

Respiratory status

GBS Dx

• Hx + Symptoms

• CSF analysis

• EMG + Nerve conduction studies

What would be found in the CSF of a GBS pt?

• High protein

• NOT high WBC count

GBS nursing interventions

• Supportive care

• Resp support

• Cardiac monitoring

• Preventing immobility complications

• Plasmapheresis

• IVIG

Labile BP

Unstable, fluctuating BP

Why does GBS cause dysrhythmias and labile BP?

Affects autonomic (involuntary) nervous system which controls heart rhythm and BP

Plasmapheresis

Removing pt plasma and replacing with substitute

Intravenous Immunoglobulin (IVIG)

High doses of immunoglobulins to stop immune attack on nerves

GBS pt education

• Disease process + LONG recovery

• Rehab (PT + OT)

• Support systems

• Preventing triggers (infection)

Which disorder involves the PNS being attacked?

GBS

Which disorder involves the CNS being attacked?

MS

Multiple Sclerosis (MS)

Autoimmune demyelination of the CNS → Scar tissue (plaques)

What do the "plaques” in MS do?

Disrupt electric impulses traveling to and from the brain

Which nerve is commonly affected by MS?

Optic nerves (II)

MS S/S

• Constant fatigue

• Blurred vision/diplopia

• Cog fog

MS mobility issues

• Muscle weakness

• Spasms

• Stiffness

• Poor coordinations

• Unsteady gait

MS sensory changes

• Numbness/Tingling/Pain

• MS hug

• Lhermitte’s sign

MS hug

Band-like sensation around chest

• Reported as chest pain/tightness

Lhermitte’s sign

Electric-shock sensation with neck movement

Cog fog

Problems with

• Memory

• Attention

• Info processing

MS pt assessment

• Functional abilities (ADLs)

• Fatigue level

• Pain + spasm nature

• Vision changes

MS Dx

• MRI

• Lumbar puncture

• Evoked potential studies

How do MRIs diagnose MS?

Visualizes plaques in brain and spinal cord

How do lumbar punctures diagnose MS?

Finds oligoclonal bands (inflammation proteins) in CNS

Evoked potential studies

Measure electrical activity in brain in response to stimuli

MS nursing interventions

• Interferon + Immunomodulators + Baclofen

• Mobility + safety

• CLUSTER ACTIVITIES

• Bladder + bowel mgmt

• Surgery

Disease-modifying therapies (DMTs) for MS

Interferon + Immunomodulators

• Reduce frequency + severity of MS relapses

What medication(s) is used to manage symptoms of MS?

• Baclofen for spasms

• Steroids for inflammation

Energy conservation techniques for Parkinson’s + ALS

Clustering activities when you have energy

• Planned rest periods

Surgical options for MS

• Deep brain stimulation

• Thalamotomy

MS pt education

• Avoid triggers

• Regulate body temp

• Safety measures

• Med adherence

MS triggers

• Overheating

• Stress

• Infection

Home safety measures for MS pt

• Fall prevention

• Burn prevention

• GET FLU SHOT

Myasthenia Gravis

Autoimmune disorder targeting ACH receptors at neuromuscular junction

• Characterized by weakness with repetitive use

ACH

Chemical messenger commanding muscles to contract

“Insufficient ACH” effect

Body produces enough ACh but cannot bind to damaged receptors

What is the hallmark of MG?

Muscle weakness worsening with repetitive use and improving with rest

What is often the first sign of MG?

Eye weakness

• Ptosis

• Diplopia

Other MG S/S

• Facial/Bulbar muscle weakness

• Generalized weakness

How does MG affect the face?

Expressionless face

Dysarthria

Slurred, soft, nasal speech

What kind of generalized weakness does MG cause?

• Difficulty holding head up

• Limb weakness

Myasthenic Crisis s/s

Diaphragm + Chest wall weakness in MG causes shallow breathing and resp failure

MG pt assessment

• Respiratory status

• Neuromuscular function

• Swallowing ability

• Vital signs (resp compromise)

MG pt neuromuscular assessment

• Ptosis, facial droop, speech quality

• Test muscle strength (fatigue with repetition?)

What is the golden standard for diagnosing MG?

Tensilon test

Tensilon test

Injecting Tensilon (anticholinesterase agent)

What is a positive Tensilon result?

Rapid and dramatic (but temporary) improvement in muscle strength

What is the antidote for tensilon?

Atropine

What are the main adverse effects of Tensilon?

Bradycardia and bronchospasm

What is found in a blood test to Dx MG?

ACh receptor antibodies

Interventions for MG pt

• Maintain patent airway

• Frequent rest periods to conserve energy

• Mealtime safety

Patent airway interventions

• Suction equipment at bedside

• Coughing and deep breathing

First-line treatment for MG

Anticholinesterase agents

What medications are given to MG pt?

• Anticholinesterase agents

• Immunosuppressants + Corticosteroids

Anticholinesterase agent examples

• Pyridostigmine

• Neostigmine

• Physostigmine

Most common anticholinesterase agent

Pyridostigmine

What do anticholinesterase agents do?

Prevents breakdown of ACh

Mealtime safety interventions

• Sit upright

• Smaller, frequent meals to avoid fatigue + aspiration

MG Crisis triggers

• Stress + fatigue

• Infections

• Extreme temps

• OTC meds

MG pt education

• Triggers

• Crisis signs

• Medic alert bracelet

Myasthenic Crisis hallmark signs

• Severe breathing

• Swallowing difficulty

Other MG Crisis s/s

• Elevated VS

• Incontinence + Oliguria

• Absent cough + swallow reflex

• Needs vent

• IMPROVES WITH TENSILON