Neuro exam II 4th test

An abnormal neuronal discharge that disrupts the brains function.

Seizure

What is this type of seizure?

Chronic neurological disorder with recurrent seizures.

May be identifiable or unknown causes and requires ongoing manangement

Epilepsy

What are the structural causes of seizures?

Stroke, TBI’s, Brain tumors, Congenital abnormalities, Previous CNS infections

What are the infectious and metabolic causes of seizures?

Infectious: Meningitis, Encephalitis, Systemic infections

Metabolic: Hypoglycemia, Electrolyte imbalances, Organ dysfunction

What phase of a seizure is this?

Hours to days before seizure

Mood changes, Anxiety, sleep disturbances

Prodromal Phase

What phase of a seizure is this?

Strange smells or tastes occur

Deja Vu and unusual sensations

Aura Phase

What phase of a seizure is this?

Active seizure period

Begins with first manifestation and ends when seizure activity stops

Manifestations vary

Ictal Phase

What type generalized seizure is this?

Stiffening of muscles and loss of consciousness for only few seconds

1-2 min clonic episode (jerking) follows

CHARACTERISTICS: Loss of consciousness, tonic stiffening, clonic jerking, possible tongue biting, urinary incontinence, postical confusion

Breathing can become irregular during the clonic phase

Cyanosis can accompany breathing irregularities

Biting of cheek during clonic, incontinence can follow

Tonic - Clonic - Grand mal

This occurs when you lose consciousness and increased muscle tone, arrythmia, apnea, vomiting, incontinence, salivation. Generally last less than 30 seconds but can be several minutes. Stiffening

Tonic

What type generalized seizure is this?

CHARACTERISTICS: Brief staring episodes, altered awareness, abrupt onset and termination, may including eyelid fluttering, no postictal confusion

Loss of consciousness for 10-30 seconds, no motor activity blinking, Can happen 100 times a day. Rare in adults, usually stops during adolescence.

Few seconds in which muscle tone is lost - followed by period of confusion. The loss of muscle tone results in falling frequently.

Absence - petit mal

What type generalized seizure is this?

Brief jerking or stiffening lasts for seconds

Consciousness reatined

Myoclonic

What type generalized seizure is this?

Sudden loss of muscle tone, fall risk, loss of consciousness possible

Few seconds muscles is lost, followed by period of confusion, loss of muscle tone usually results in patient falling

Atonic / akinetic

What type of seizure is this?

Originate in one hemisphere. Motor and nonmotor manifestations

Include: Altered awareness, motor symptoms, sensory disturbances, emotional changes, autonomic changes

Focal seizures

What type of seizure is this?

Medical emergency where the seizure lasts longer than 5 minutes

Repeated seizure without recovery

Complications: Hypoxia, permanent neurological injury, death

Can involve any type of seizure

Status epilepticus

What are your abort and prevention medications for Status Epilepticus?

Abort: Benzo’s (Diazepam, Lorazepam)

Prevention: Fosphenytoin, Phenobarbital

What phase of a seizure is this?

After the seizure is over

Findings: Confusion, sleepiness, headache, weakness, nausea, temporary neurologic deficits

Postictal phase

What are the diagnostics for Seizures?

CT, MRI, EEG, Labs (CBC, toxicology screening, serum glucose), Lumbar puncture

What is the assessment for a seizure?

ABC’s is first, Duration of seizure, LOC, type of movement (Tonic/Clonic), Aura presence, Injuries

What is the nursing care DURING a seizure?

Protect airway, turn to side, time seizure, stay with patient, lower to floor if possible, do not play anything in mouth, do not restrain, pad rails, suction as needed

What medication is this for a seizure?

Serum leve is 10-20. Less than 10 s high risk for seizure (Call doctor). High levels need to be held

Gingival hyperplasia is expected, soft tooth brush, no alcohol mouthwash, oral care

SE: slows everything down, check BP/HR before giving

DO NOT give with oral contraceptives

Phenytoin

What medication is this for a seizure?

DO NOT give with valproic acid (will give rash, muscle pain, weakness)

SE: Dizzy, ataxia, rash

Lamotrigine

What is the initial injury for spinal cord injury?

24 hours or less is when you will see what permanent damage may occur. Give steroids to decrease inflammation

This inflammatory response in SCI is harmful because of lack of space for tissue expansion

Edema Secondary to inflammation

What is this type of injury related to Neuro?

Damage to the spinal cord resulting in fuctional loss: Concussion, contusion, compression, tearing, laceration, transection, ischemia

Risk factors: Ages 16-18, male gender, high risk physcial activity, driving under the influence of alcohol

Clinical Manifestations: Inability to breathe, paraplegia, quadriplegia, loss of bowel, bladder, sexual function. chronic pain. hypotension, impaired temperature

Spinal Cord Injury

What type of plegia is this in spinal cord injury?

Below T1 paralysis or presis (weakness) of lower extremities T2-S5 - loss of feeling or movement in lower parts of the body

Paraplegia

What type of plegia is this in spinal cord injury?

Cervical region injury - paralysis or paresis of all 4 extremities

Quadriplegia

What type of plegia is this in spinal cord injury?

C1-T1 - loss of feeling or movement in lower parts of the body

Tetraplegia

What part of the body is related to this spinal cord injury?

Partial or complete quad/paraplegia

Respiratory dysfunctions - may be vent dependent

Partial or complete paralysis of all 4 extrem and loss of bladder and bowel control

Cervical

What part of the body is related to this spinal cord injury?

Seen in partial or complete paraplegia

Loss of bladder and bowel control, alteration in sexual function

Partial or complete paralysis of lower extremities and major control of body trunk

Potential complication of autonomic dysreflexia - injury above T6

Thoracic

What part of the body is related to this spinal cord injury?

Partial or complete paralysis of lower extremities

Loss of bowel and bladder control, alteration in sexual function

Lumbar

What is the nursing implementations for spinal cord injury?

Proper immobilization of neck to stabilize cervical spine, traction maintained at all time with cervical injuries, IF CPR NEEDED, uses jaw thrust rather than head tilt chin lift maneuver

What is this complication related to SCI?

Not hemodyamiccaly significant. Do not need to worry about V/S. Decreased reflexes, loss of muscle tone, loss of sensation, flaccidity below level of injury. It is vasogenic and lasts days to months

Temporary loss of reflexes and sensation, lack of thermoregulation, and flaccid paralysis below level of injury

Medications: Methylprednisolone - decrease inflammation

Spinal Shock

What is this complication related to SCI?

Hemodynamically significated. Worried about the V/S. Loss of vasomotor tone. Hypotension, bradycardia, warm and dry extremtities. Lasts minutes to hours. Typically injuries above t6.

Loss of sympathetic innervation; causes loss of sympathetic nervous system activity, with unopposed parasympathetic response leading to instability of vitals

S/S: Bradycardia, hypotension, change in LOC, metabolic acidosis

Interventions: Raise HOB slowly, assist with insertion of hemodynamic monitoring device, admin IV fluids, admin meds, prepare for pacing

Neurogenic shock

What is this complication related to SCI?

MEDICAL EMERGENCY

Life-threatening hypertension following a SCI t6 or above

Caused by return of reflexes and uncompensated reaction of the sympathetic nervous system; happens within first year of injury

S/S: Severe hypertension (240-300/120-150), Severe headache, pallor/coolness below level of lesion, flushing/sweating above level of lesion. blurred vision, pilomotor erection. upset GI system

Interventions: Elevated HOB 45/sit upright, notify, immediate catherization, bowel evacuation, removal of all skin stimuli, management of BP

Autonomic Dysreflexia

Pain that arises from stimulation of meninges, vessels, nerves, muscles, and facial structures

Headaches

What type of headaches is this?

Pain like a band squeezing the head; bilateral

Stress and poor posture, 30 min to 7 days

Most common type of headache, bilateral feeling of pressure around head

Phonophobia/Photophobia

Tension-type headache

What type of headaches is this?

Characterized by repeated headaches that occur for weeks or months at a time, followed by periods of remission

One of the most severe forms of head pain, occurs less frequently than migraine and onset between 20 and 50 years

Severe unilateral orbital pain, lacrimation and nasal congestion, client may pace or rock

Medications: Triptans, Ergotamine, topiramate, Calcium Channel Blockers verapamil, amlodipine, corticosteroids, melatonin, glucosamine

Home oxygen at 12 L for 15 -20min at onset of headache

Cluster headaches

What type of headaches is this?

Pain, nausea, and visual changes on one side of the face

Triggers: Stress, odors, lights, weather, hormones, caffiene, skipped meals

4 phases

Fatigue/cravings, visual and sensory changes, throbbing pain, brain fog

Medications: NSAIDS, acetaminophen for mild. “-triptan” meds for severe

Migraines

What are the secondary headache red flags?

Thunderclap headache, Neurologic deficits, Fever/Neck stiffness, New headache after age 50

What part of the spine is related to this SCI?

These injuries will be ventilator dependent

C1 to C4

What part of the spine is related to this SCI?

These patients will be limited proprioception

C1 to C8

What part of the spine is related to this SCI?

These patients will be affected on trunk movement, and lack abdominal control

T1 to T8

What part of the spine is related to this SCI?

These patients will have limited abdominal control

T9 to T12

What part of the spine is related to this SCI?

These patients will have loss of bowel and bladder functioning, and will affect sexual function

L1 to S5

What is this neurological disorder?

SAFTEY IS PRIORITY

A chronic autoimmune CNS disease where the immune attack on myelin; snowflake disease

A slowed nerve conduction; relapse and remission

Immune activation —> inflammation —> demyelination —> plaque formation —> neurologic deficits

Risk Factors: Genetics, onset 20-40 years, Female, relapse triggers, viruses/infections, cold climate, physical injury, emotional stress, pregancy, fatigue, overexertion, temperature extremes, hot shower/bath

Clinical manifestations: Vision; Monocular or homonymous vision loss, diplopia, optic neuritis. Cognitive; difficulty with concentration, emory impairment, executive function impairment. Sensory; paresthesia, loss of sensation, dysesthesias. Psychiatric; anxiety, depression. Vestibular; vertigo gait issues. Bulbar; dyshphagia, dysarthia. Motor; fatigue, spasticity, tremor, weaknes. Urinary and Bowel; incontinece, urgency, retention, reflux, diarrhea, constipation. Head intolerance; avoid overheating and hot baths (Uhthoff syndome)

Multiple Sclerosis

What type of multiple sclerosis is this?

Progressive worsening of neurological manifestations without remissions

Primary progressive MS-PPMS

What type of multiple sclerosis is this?

Occurs before a client meets the diagnostic criteria for MS

Clinically Isolated Syndrome (CIS)

What type of multiple sclerosis is this?

Progressive worsening of neurological manifestations with initial periods of relapses and remission

Secondary Progressive MS-SPMS

What type of multiple sclerosis is this?

Periods of exacerbation followed by remission, without progression of MS

Relapse Remitting MS-RRMS

What should we avoid for MS?

Smoking, sickness, sun, and stress

What is the system that diagnosis Multiple Sclerosis?

McDonald’s Criteria for Diagnosis of MS

What is the medical management of MS?

Focus on improving speed of recovery from attack, reducing number of attack, slow progress of the disease

What is the management for Acute Relapse of MS?

IV methylpredinisolone and plasma exchange for severe relapse (Steroids for relapse)

What medications are given inbetween relapses of MS?

Beta interferons like Avonex and Rebif

What would we give for a patient with muscle pain/spasms?

Baclofen

What would we give a patient with neuropathic pain?

Gabapentin

What would we give a patient with flaccid bladder or decreased function of bladder?

Oxybutynin

What are the four P’s of mobility for MS?

Pacing, Prioritization, Planning, Position

Which of the four P’s of mobility is this for MS?

Integrate short breaks into activities regularly to avoid overextertion and proceed with activities at a moderate pace

Pacing

Which of the four P’s of mobility is this for MS?

Complete important tasks before others that are less important and rest as needed

Prioritization

Which of the four P’s of mobility is this for MS?

Determine which tasks need to be accomplished on which day and organize the tasks according to priority and effort

Planning

Which of the four P’s of mobility is this for MS?

Practice using good posture, body mechanics, and ergonomics, placing needed supplies wthin reach

Positioning

What is the gold standard for MS?

MRI

What is the nursing interventions for MS?

Encourage ROM, Administer meds as prescribed, Implement safety, Patch eye daily PRN, Teach self catheterization if needed. Teach med adherence, cooling strategies, energy conservation, and smoking cessation

What is this neurological disorder?

NEUROLOGICAL EMERGENCY

An acute autoimmune disorder related to the peripheral nervous system. Demyelination without significant axonal destruction

Demyelination of the peripheral nerves; usually follows infection and potentially reversible but often reversible

Triggers: Campylobacter infection, Flu, CMV, Epstein-Barr Virus, Respiratory infection

Complications: Respiratory arrest, aspiration, VTE, Pressure injuries, Contractures

S/S: Motor; ascending weakness, paralysis. Sensory; paresthesias, neuropathic pain. Autonomic; blood pressure instability, tachycardia. Respiratory; dyspnea, weak cough

HALLMARK SIGNS: Ascending paralysis, Areflexia, Recent Infections, Bilateral weakness

Guillian Barre

What is the highest nursing priority for Guillian Barre?

Respiratory rate. Oxygen saturation, Breath sounds, Vital capacity

What is the first line therapy for Guillian Barre?

IVIG - Intravenous Immunoglobulin

What is the most effective treatment for early Guillian Barre?

Plasmapheresis Plasma Exchange (Removes harmufl antibodies)

What are the interventions and teachings for Guillain-Barre Syndrome?

Interventions: Turn frequently, Perform ROM, VTE protection, Relaxation techniques, Establish communication method, Pain management

Teaching: Recovery takes weeks to months, Respiratory monitoring, Rehab

What is this neurological disorder?

NO CURE; respiratory failure is leading cause of death

A progressive degeneration of upper and lower motor neurons that results in kuscle weakness, paralysis, and eventual respiratory compromise; HALLMARK is atrophy and muscle weakness

Average time is 2-5 years of onset of death

Complications: Aspiration, Respiratory failure, Pneumonia, Pressure Injury, DVT, PE

Clinical Manifestations: Early; muscle weakness, muscle cramps, fasciculations. Bulbar Symptoms: dysphagia, dysarthia, voice changes. Advanced Disease; paralysis, respiratory compromise

MRI/CT to rule out causes

ALS (Amyotrophic Lateral Sclerosis)

What do we give to slow the progression of ALS?

Riluzole (Rilutek)

What is the nursing interventions and teaching for ALS?

Interventions: Prevent Aspirations (PRIORITY ACTION), Support respiratory function, prevent skin breakdown, promote mobility, support communication

Teaching: Report increased difficulty swallowing, disease prognosis and process, communication strategies

What is this cranial nerve disorder?

Cranial Nerve V

Usually a unilateral, severe, brief, stabbing, recurrent pain in the distribution of one or more branches of the trigeminal nerve

HALLMARK: Bouts of sharp facial pain

Clinical manifestations: Pain, and attack vary in frequency

Triggers: Touch, Cold, pressure, blast of air, chewing, talking, smiling, shaving, brushing teeth, or a breeze

Trigeminal Neuroalgia

What is the first line therapy for Trigeminal Neuralgia?

Antileptics (Carbamasepine, Oxcarbazepine, Gabapentin)

What is this Cranial Nerve Disorder?

Cranial Nerve VII; Inflammatory Disorder

Onset is usually sudden and almost always involves one side

HALLMARK: Unilateral facial weakness

Pain behind ear and neck may precede the paralysis; often associated with herpes vesicles near ear

Clinical Manifestations: Facial paralysis, drawing sensation of affected side of face, Unilateral weakness of facial muscles, Inability to wrinkle forehead, close eyelid, pucker lips, Face appears asymmetric with drooping of mouth and cheek, loss of taste anterior 2/3 of tongue, increased saliva,

Bells Palsy

What is the management for Bells Palsy?

Corticosteroids, Antivirals (“-virs), Analgesics, eye protection, gentle massage, moist heat, electrical stim, facial exercises

What is this neurological disorder?

Autoimmune disorder

Ragdoll illness; muscle weakness, that they can’t control without treatment (Different from Parkisons)

HALLMARK: fatigue that improves will rest

Complications: Myasthenic crisis, cholinergic crisis

Clinical Manifestations: Diplopia, ptosis, Dysarthia (slow slurred speech), dysphagia, dysphonia, smiles become a snarl or grimace, muscle groups weaker after use toward end of the day, fatigue and weakness exacerbated with; stress, fever, overexertion, exposure to heat, relief with rest

Myasthenia Gravis

What diagnosis is related to Myasthenia gravis?

Serological testing, repetitive nerve stimulation test, tensilon test (Edrophonium), MRI of thymus gland, EMG

What is the first line therapy for Myasthenia Gravis?

Pyridostigmine

What are the intervention and teachings for Myasthenia Gravis?

Interventions: Admin meds as ordered, Elevate HOB, establish communication method, plan meals when meds at peak levels, offer soft foods, plan for rest periods

Teachings: Take meds as prescribed, keep meds with patient at all times, medic alert bracelet, avoid public places, obtain vaccines, prevent fatigue, referral

What are we assessing for with Myasthenia Gravis?

Assess breath sounds, vital capacity, cranial nerves, dysphagia, nutritional intake, dysarthria

What does dopamine do for the body?

Maintains fluidity and motion

What does acetylcholine do for the body?

Causes rigidity in the body

What medication do we give for neurogenic shock?

Atropine

What test is given for Myasthenia Gravis to determine/diagnose the disease?

Tensilon Test

What do we give when the symptoms gets worse (cholonergic crisis) during the tensilon test?

We give atropine (emergent drug before test) and decrease the medication

What is this neurological disorder?

Progressive debilitating disease where there is a loss of dopamine-producing brain cells; decreased dopamine

Clinical Manifestations: Resting tremors (pill rolling), muscle rigidity (cogwheel- arms passive to body), slowness of movement (Bradykinesia), Loss of movement (akinesia)

TRAP: Tremor, Rigidity, Akinesia, Postural deformity

Risk Factors: Onset between age 40-70, male, genetics, exposure to environmental toxins, chronic use of antipsychotic meds

Diagnosis: Two or more cardinal symptoms with asymmetrical presentation: Tremor, Akeinesia/Bradykinesia, Rigidity or Postural instability

Parkison’s Disease

What is the first line drug used for Parkison’s Disease?

Carbidopa with levodopa

What is the medical management of medications for Parkison’s disease?

Antiparkisonian agent - Carbidopa/levodopa

Anticholinergics - Trihexyphenidyl and Benztropine

Dopamine-receptor agonists - Pramipexole, Ropinirole

COMT inhibitors: Entacapone

MAO-B inhibitors - Selegilline and rasagilline

What antiviral do we give for parkinson’s disease and what does it do?

Amantadine (Increases dopamine release and inhibits dopamine reuptake)

What is this related to Parkinson’s disease?

A neurosurgical procedure whereby a tiny electrical probe is placed in the globus pallidus which is then heated to 8- degress for 60 seconds, to destroy a small area of brain cells resulting in les rigid, easy tremors

Pallidotomy

How do we assess an adults ear?

Top of auricle grasped and gently pull up and backward

How do we assess a childs ear?

Slightly down and backward

What auditory hearing test is this?

Tuning fork placed on the top of the forehead and determins what the patients hears in both ears

Weber test

What auditory hearing test is this?

Tuning fork is put on the ear canal against the bone

Rinne Test

If sounds is heard equally in both ears in a weber test, what could this indicate?

Indicates normal hearing response

If sound is louder in the affected ear during a weber test, what could this indicate?

Indicates conductive hearing loss

If sound is louder in unaffected ear during a weber test, what could this indicate?

Indicates Sensorineural hearing loss

If air conduction is greater than bone conduction during a Rinne test, what could this indicate?

Indicates a normal response to rinne test

If bone conduction is greater than air conduction during a Rinne test, what could this indicate?

Indicates conductive hearing loss during Rinne test