Neuro Assessment

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Neuro Assessment

• Megan McClintock, MS, RN
• 10/27/11

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• Neurotransmitters
• Acetylcholine (activates muscles)
• Decreased in AD, MG
• Dopamine (affects mood)
• Decreased in PD
• Lower motor neuron lesions
• Cause weakness or paralysis
• Denervation atrophy
• Flaccidity, hyporeflexia
• Upper motor neuron lesions
• Cause weakness or paralysis
• Disuse atrophy
• Spasticity

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Peripheral Nervous System

• Spinal Nerves
• ANS
• Sensory fibers
• Motor fibers
• Dermatomes/myotomes
• Cranial Nerves
• ANS
• Sympathetic
• Parasympathetic

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Vertebral Column
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Assessment

• Cerebral function (mental status)
• General appearance/behavior
• Cognition
• Mood/affect
• Cranial nerves
• Motor system
• Weakness (pronator drift)
• Muscle tone
• Balance/coordination (cerebellar function)
• Sensory system
• Touch, pain, temp, vibration
• Position (Romberg test)
• Reflexes

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Diagnostic Studies

• Lumbar Puncture
• Cerebral Angiography
• CT
• MRI MRA
• PET SPECT
• Myelogram
• EEG
• EMG
• Ultrasound

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Headache

• Common source of pain
• Primary
• Tension
• Migraine
• Cluster
• Secondary
• Symptom of other primary disease process

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Tension Headache

• Pain is bilateral
• Squeezing or tight band sensation
• Mild to moderate intensity
• Unaffected by activity
• No prodrome, no nausea or vomiting
• May have photophobia and/or phonophobia

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Migraine Headache
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Stages of Migraine

• Prodrome
• Aura (classic migraine, 10)
• Headache
• Resolution
• Interval

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How do you know its a migraine?

• More than 5 occurrences
• Lasts 4-72 hours
• Has at least 2 of these symptoms
• Unilateral
• Pulsating
• Nausea and/or vomiting
• Moderate to severe intensity
• Worse with physical activity
• Photophobia/phonophobia
• Not caused by other problems

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Cluster Headaches
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Headache Loci
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Headache as Symptom

• Brain tumor
• Trigeminal neuralgia
• Tooth impaction
• Viral illness
• Sinus infection

• Subarachnoid hemorrhage
• CO poisoning
• Altitude sickness
• Arteritis

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Headache Medications

• Tension
• Nonopioid analgesics
• Sedative, muscle relaxant, tranquilizer or
  codeine
• Fiorinal (can be habit forming)
• Migraine
• Triptans (cause vasoconstriction)
• Preventive drugs (Topamax, Depakote)
• Cluster
• 100 oxygen
• Triptans

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Headache Interventions

• Thorough assessment
• Daily exercise
• Relaxation techniques
• Quiet, dimly lit environment
• Massage
• Moist hot packs
• Dietary counseling
• Medications

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Seizure Disorders

• Dysfunctional neuronal firing in one or more
  lobes of the brain
• Frontal
• Temporal
• Parietal
• Occipital

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Causes of Seizures

• Epilepsy

• Seizures as Symptoms

• Brain injury
• Infection
• Genetic abnormality

• Hypoxia
• Hypoglycemia
• Drug alcohol withdrawal
• Acidosis
• Fever
• Lupus
• Septicemia

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Types of Seizures
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Classification Frequency
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Generalized Tonic-Clonic Seizures
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Simple Partial Seizure
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Complex Partial Seizures
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Seizure Complications

• Status Epilepticus
• Single seizure lasting gt 30 minutes
• Repeated seizures without regaining consciousness
  in between
• Brain consumes 300-500 more glucose and oxygen
• Neuronal death occurs with exhaustion

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Seizure First Aid
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Drug Therapy

• Dilantin (phenytoin)
• Gingival hyperplasia, hirsutism
• Tegretol (carbamazepine)
• No grapefruit juice
• Phenobarbitol
• Depakote (divalproex)
• Zarontin (ethosuximide)
• Klonopin (clonazepam)
• Felbatol (felbamate)
• Aplastic anemia, liver toxicity

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Nursing Interventions

• Carefully observe and record
• Safety during a seizure
• Airway
• No restraints
• Nothing in the mouth
• Suction, ambu bag, oxygen at bedside

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Multiple Sclerosis (MS)
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MS Pathophysiology

• Unknown trigger stimulates immune response -gt
  inflammatory response
• -gtmyelin sheath damage -gt scar/plaque
  formation -gt nerve impulse interruption

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Types of MS

• Benign/stable
• Relapsing-remitting
• Relapsing-progressive
• Chronic-progressive

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Symptoms
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Treatment

• ACTH (adrenocorticotropic hormone)
• Prednisone
• Interferon drugs
• Flu-like symptoms, sensitivity to sun
• Immunosuppresive drugs
• Additional drugs for symptom control
• Exercise
• Healthy diet

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Parkinsons Disease
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Symptoms

• Gradual and insidious
• Triad of PD
• Tremor
• Rigidity
• Bradykinesia (Bradykinesia Video)
• Can also have depression, anxiety, short-term
  memory probs
• Sleep disorders

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Treatment

• Levodopa with carbidopa (Sinemet)
• Other drugs (reserve combo therapy for later in
  the disease)
• Physical and occupational therapy
• Surgical management for relief of symptoms
• Diet

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Nursing Care

• Fall prevention
• Have them consciously think about stepping over
  an imaginary line
• Drop rice kernels and step over them
• Rock from side to side
• Lift the toes when stepping
• Take one step backward and two steps forward
• Remove rugs
• Elevated toilet seat
• Slow-stretch-hold movements
• Wide base of support

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Myasthenia Gravis (MG)
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MG Assessment

• Physical Exam
• Progressive muscle weakness
• Fatigue
• Speech difficulties
• Ocular palsies
• Ptosis
• Diplopia
• Respiratory distress
• Cough, gag reflexes

• Diagnostic Tests
• EMG
• Tensilon test (pg 1513)
• Myasthenic crisis
• Cholinergic crisis

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Treatment

• Anticholinesterase drugs (Mestinon or
  pyridostigmine)
• Alternate-day corticosteroids (prednisone)
• Immunosuppressants (cyclosporine, Imuran)
• Avoid many classes of drugs
• Thymectomy
• Plasmapheresis
• Immunoglobulin G

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Nursing Care

• Distinguish between myasthenic crisis and
  cholinergic crisis
• Semisolid foods
• Schedule drugs so peak action is at mealtimes

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Restless Legs Syndrome (RLS)

• Idiopathic or secondary
• Related to abnormal iron metabolism and problems
  with dopamine
• Sx paresthesias to severe pain to calves
  primarily when sedentary, sleep disturbance
• Tx treat underlying condition, parkinson drugs,
  antiseizure drugs

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Amyotrophic Lateral Sclerosis (ALS)

• Lou Gehrigs disease
• Rare, progressive disorder
• Death from respiratory failure within 2-6 years
• Sx weakness of upper extremities, dysarthria,
  dysphagia
• Tx none
• Remains cognitively aware while wasting away

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Huntingtons Disease (HD)

• Genetic disease with deficiency of Ach and GABA
• Sx chorea, worsening gait, risk for
  aspiration/malnutrition, cognitive deterioration,
  loss of speech
• Need 4000-5000 calories per day
• Death within 10-20 years, no cure
• Xenaxine for chorea, haldol, valium,
  dopamine-depleting agents

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Alzheimers Disease (AD)

• Chronic, progressive, degenerative
• Cause is unknown
• Findings amyloid plaques, neurofibrillary
  tangles, loss of connections between cells, cell
  deaths

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Symptoms

• Warning signs (pg 1524)
• Subtle deterioration in memory (1st sign)
• Loss of recent memory
• Decrease in personal hygiene
• Loss of concentration
• Agitation, aggression
• Significant cognitive impairments
• Loss of long-term memory

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Treatment

• Cholinesterase inhibitors
• Namenda (memantine)
• Antidepressants
• Antipsychotics

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Nursing Care

• Early recognition of the disease
• Memory aids and cues
• Give simple directions
• Use distraction, rather than confrontation
• Limit number of choices
• Provide space for safe pacing
• Provide boundaries (red tape)
• Dont ask why
• Judicious use of restraints
• Interventions for sundowning

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Nursing Care

• Fall prevention
• Prevent wandering
• Medic Alert bracelet
• Nutrition pureed food, thickened liquids,
  supplements
• Good oral care
• Infection prevention
• Prevention of incontinence, constipation
• Caregiver support

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Dementia vs Delirium

• Insidious onset
• Symptoms progressive
• Duration of months to years
• Progressive impairment
• Consistently poor performance in mental status
  testing
• Caused by neurodegenerative conditions vascular
  disorders

• Rapid onset
• Lucid intervals
• Duration of hours to 1 month
• Fluctuates in severity
• Mental status testing improves when patient
  recovers
• Caused by a interaction of their underlying
  condition with a precipitating event

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Nursing CareDementia Delirium

• Careful assessment (use Mini-Mental Status Exam
  MMSE)
• CT/MRI to look for vascular changes
• Similar care as for AD

• Recognition of high risk pts
• Careful assessment (use Confusion Assessment
  Method CAM tool)
• Labs, CT/MRI only if injury suspected
• Eliminate precipitating factors
• Calm, safe environment
• Personal contact
• Eyeglasses, hearing aids
• Drugs only for severe anxiety