Neuro Med-Surg-outline



Neuro Med-Surg-outlineNEUROLOGICAL ASSESSMENTNEURO PHYSICAL EXAMINATIONHistoryAppearanceAssess speech, affect, and motor functionPersonal and Family HistoryEthnic and cultural backgroundADL’sCurrent Health Problems and Social HistorySeizures, Tremors, Weakness, Headache, Difficulty swallowingPHYSICAL ASSESSMENTFollows logical sequence – start from the head downHigher levels of neurologic function to lower levels – name? where are you?Constant comparison of findings Five Areas of Neurologic Assessment: Mental status and speech1st - Level of Consciousness and OrientationA change in a persons LOC is the first indication of decline in neurological function.Ask questions that require more than a yes or no answer.Alert – awake and responsive, orientedLethargic – sleepy but arousable, delayed responseStuporous – arousable with difficulty, use sternal rub to arouse (vigorous stimulation to arouse)Comatose – not arousable A change in a persons LOC is the first indication of decline in neurological function. Confusion/Memory Problems:LOC - We do this by asking questions of orientation Appearance and behavior – are they appropriate How does pt. behaveHow is the pts grooming – oral care? Facial hair?Ask family if it is normal or if it’s a changeSpeech – can the string words togetherHow well can pt express himself – can he string together words to make a sentence, does it make sense, can he carry a intelligent conversationIs speech fluent/fragmented – is the pace correct, the volume = low if confusedAssess for dysarthria = can’t get words out clearly, need to articulateAssess for comprehension – do they squeeze your hand, do they follow commandsCognitive function – do they think in an orderly mannerThought content – how they think, is thinking in tack, evaluate their cohearance, are they seeing thing that don’t exist, dillusions (believes in things that aren’t true)Abstract thinking – thinking outside the box. Judgment – ask what they might do if room is on fire. How do they handle their money.Emotional status – if their confused, they may have depression. (treat their depression, cognitive problems go away) How do they feel about the future. Hopeful, etcConstructional abilityAffects patients ability to perform simple tasks and use various objectsask what’s this? And.. What do you use it for?(Can use Mini Mental status exam) – Look up in BOOK!GLASGOW COMA SCALEUse if your pt can’t communicateIf it’s an emergencyIf pt consciousness is in and out – use the Very reliable tool and used by everyone to assess neuro function, when you use it start with the least noxious stimuli (least in your face stuff) to the more noxious stimuli.Addresses 3 areas of neuro functioningDone every 4 hoursOverview of level of responsivenessEvaluate neuro status of head injury patientEvaluates motor, verbal, & eye-opening Each response awarded a numberSum gives indication of severity of coma & prediction of possible outcomeThree Areas of Memory Loss:Assess memory lossRecent memory lossLong-term or Remote Memory – B-day, schools attended, city of birth, mother’s maiden name.Recall or Recent Memory – accuracey of medical history, health care provider, type of car you drive, how did you get here?Immediate or New Memory – give 2 or 3 words to remember, distract them then have them repeat back words,Cranial nerve function12 pairs of cranial nervesS: SENSORY 3 are entirely sensory – I, II, VIIIM: MOTOR5 are entirely motor – III, IV, VI, XI, & XIIB: MIXED4 are mixed – V, VII, IX, & XEmerge from the lower surface of the brainMost innervate the head, neck, & special sense structure S M BOTH 12 pairs Help to remember nervesSomeSay Marry Money But My Brother Says Bad Business Marries MoneyOlfactory OpticOculomotor Trochlear TrigeminalAbducens FacialAcousticGlossopharyngeal Vagus Spinal AccessoryHypoglossalObtuse Octopus TriedTo Abduct AFemale Artist Grabbing Vigorously Spinning HerCranial nerve Function Symptom / sign of damage Olfactory (I) Smell Anosmia Damage to sinuses affect smells – Assess smell by: close one nostril but different scents (coffee, vanilla) see if they can name what under their nose.Optic (II) Vision Blindness Assess – opthalmascope to check the optic nerve, light goes through the pupil to the retina, eye chart, test visual fields, Oculomotor (III) Eye movement (elevation, adduction) Eye deviates down & out. Loss of pupillary/accommodation reflexes Trochlear (IV) Eye movement. (depression of adducted eye) Diplopia, lateral deviation of eye Trigeminal (V) Facial sensation. Mastication. Facial anesthesia. Loss of pain sensation. Insignificant. Weakness/loss of mastication. Pain is excrucitiating, hurts so bad you don’t want to eat.Abducent (VI) Eye movement (Abduction) Medial eye deviation Facial (VII) Facial expression. Taste. Salivation & lacrimation. Paralysis of facial nerve muscles (+ hyperacuisis). Loss of taste (anterior 2/3rds of tongue). Dry mouth, loss of lacrimation. Belle’s Palsy – paralysis of facial nerve muscleVestibulocochlear (VIII) Balance. Hearing. Vertigo, dysequilibrium, nystagmus. Hearing. Glossopharyngeal (IX) Taste. Loss of taste (posterior 1/3rd of tongue). Loss of gag reflex. Vagus (X) Swallowing & talking. Cardiac, GI tract, respiration. Taste. Dysphagia & hoarseness of voice. Loss of cough reflex (larynx/pharynx), loss of taste (hard palate)Valsalvo manuever stimulates the vagal nerve Spinal Accessory (XI) Pharynx/larynx muscles. Neck & shoulder movement. Head turning/shoulder shrugging weakness. Hypoglossal (XII) Tongue movement. Atrophy of tongue muscles, deviation on protrusion, fasciculaations XII. Check by asking, stick your tongue out and wiggle itCranial nerve continued Bell’s Palsy:Facial paralysis r/t inflammation of the 7th cranial nerve palsey Results in weakness or paralysis of facial musclesCause unknown but thought to be r/t vascular ischemia, viral disease, autoimmune disease or combination of allRapid onsetGoes away by itselfMay come from tooth infection, ear infection, virus, S/S: distortion of the face from paralysis, increased lacrimation, painful sensations in the face, behind the ear, and the eye, possible speech difficulties and inability to eat on affected sideManagement: maintain muscle tone, ensure spontaneous recovery within 3-5 weeks, steroids (to get rid of inflammation), pain meds, heat (promotes blood flow), electrical stimulation(help prevent atrophy) and surgery (surgical decompression, especially if it’s a tumor causing it)If nerve stays pinched, it scarsPt. teaching and self-care: eye care, facial exercises and avoidance of coldTrigeminal Neuralgia:Disease of 5th cranial nerveSpasms with stab-like pain radiating down nerve pathwayCaused by degeneration of nerve or increased pressureCause is unknown, causes spasms or proxcisoms 400 x more common in pt with MS.Treated with antiseizure medications (Dilantin) (tegratol) (Baclofin – antispasm)Severe cases treated with surgeryVERY PAINFULNursing management: preventing pain, identifying triggering events Cut down on electrical spasms, nironton, liraca (gaba), Watch for signs of anxiety, depression, because pain is so bad people want to kill or hurt themselves. SPINAL NERVE31 pairs of spinal nerves8 cervicalCervical and thoraxic The nerves exit above the numbered vertebra in the thoraxic all the way below that vertebra12 thoracic5 lumbar5 sacral1 coccygeal Sensory functionPain – Light touch – same thing but use something softer, Q-tip, sharp or dull?Vibration - Position – have pt close eye, move big toe or finger and ask pt if it is pointing up or down. It test cerebellum function. Have to have an intact cerebellum to have it.Discrimination – assess the cerebral cortex (outerlayer) stereognosis= with out looking at the object and identifying what it is. Test cerebral cortex.Pain - Make sure sensation is same on both sides, have pt. close eyes, Sharp or dull?Diabetics – feet hurt, but they can feel light touch.Motor functionMuscle tone = a state of slight contraction usually present in muscles that contribute to posture and coordination, normal healthy state of your muscles.Muscle strengthCerebellar functionMuscle Tone:Represents muscular resistance to passive stretchingROM arm ROM legSlight resistance is normalLet leg fall - If leg falls and is turned outward it is a problemMuscle Strength:Observe gait (should be heel to toe and straight) and motor activitiesMove muscle groups against resistanceGraded on a 5 pt. scaleFive Point Scale For Strength:0: no contraction1: minimal contractile power (see it flicker but they can’t move it.2: can move but not overcome the force of gravity3: sufficient strength to overcome the force of gravity4: fair5: indicates full power of contractionFlexion and extension against resistanceNormal between 3-5 Cerebellar function:Site of Balance & coordinationGaitRomberg’s test – pt stand up with eyes open feet and together and hands to side, and close eyes (same as alcohol test) positive if they can’t do it.Finger to nose test – should be accurate and smoothRapid alternating movement tests – fingers to thumb. (Parkinson’s pt can’t do it) Pronate and supanate quicklyShould be able to sit and stand with out help, should be able to turnaround.ReflexesNeed reflex hammerAchilles reflex may be absent in elderlyGraded on 0 to 4+ scale –Deep Tendon Reflex Scale: 0: absent+1: diminished impulses+2: normal impulses+3: increased impulses+4: hyperactive impulses (clonus)= hyperactive reflexesDTR – Plantar / Babinski Reflex Positive babinski = abnormal,Upper motor neuron lesion – motor cortexS/s = loss of vol. control, increased muscle tone, muscle spasticity, hyperactive and abnormal relflexes.R/t – stoke, bleed or injury to spinal cordLower motor neuron lesionOccurs when motor nerves are severed between a muscle and a spinal cord, usually caused by trauma, infection, compression of nerve roots by herniated discs.s/s = loss of leg control, decreased muscle tone, flacid muscle control (no movement), muscle atrophy, ablsent or decreased reflexesDTR – Brachioradialis ReflexC5 and C6Need to be relaxed, hit in marked spotsLower arm should flex and palm will supinate (turn upwards)DTR – Biceps ReflexHave to be relaxed , hitRepeat and compare to other armC5 and C6 nerve root cervical stenosis or herniated cervical disc – absent reflex or weak reflexDTR – Triceps ReflexC6 and C7. Tap tricep tendon, should flick and contract, and may be elbow extension.DTR – Knee JerkL3-4 intervation Strike quadraceps tendon directlyReflex contraction of quadraceps muscleDTR – Ankle ReflexSyatic nerve – S1Should see planter flexionGendrassik - DTR – ClonusA sudden brief jerking contraction of a muscle or muscle groupMost often seen in seizures, Tonic, clonic DIAGNOSTIC ASSESSMENTNeuro – diagnositc fieldNeurologist - will dx the problem, if surgical they will send to a surgeonCat Scans (CT) – least invasive, least expensiveMagnetic Resonance Imaging (MRI) – more invasive, more expensive , can’t have one if you weigh more than 300 lbs.Magnetic Resonance Angiography (MRA)- looking at vascularture, at blood vesselsElectroencephalography (EEG) - Evoked Potential Studies (EPS) - Electromyography (EMG) – applying elect. Stimulation to nerves, invasiveNerve Conduction Studies (NCV) non invasiveMyelography - Lumbar Puncture/Cerebral Spinal Fluid (LP/CSF) – spinal tap COMPUTED TOMOGRAPHYNarrow beams of x-ray in layersPerformed with and/ without contrastMust lie perfectly stillNo talkingMust not move faceMotion may cause distortionShow all kinds of tissue,Stomach problemsUse any whereBrains – shows all structures just not in great detailQuick, accurate, easyAdd contrast - usually looking for some kind of tumorNo contrast – bleeds, etc. CT SCANDistinguishes bone, soft tissue, and fluidsIdentification of:TumorsInfarctions (clot causing tissue death)HemorrhageHydrocephalusBone MalformationsMAGNETIC RESONANCE IMAGING (MRI)Uses powerful magnetic field to obtain images of different areas of bodyMagnetized photons within body align like small magnets in this magnetic fieldAfter bombardment with radiofrequency pulses, protons emit signalsSignals convert to imagesDon’t wear anything that has metal, good for detecting damages to brain and spinal cord5 steps above a Cat Scan.Potential for identifying cerebral abnormality earlier & more clearly Provides info about chemical changes within cellsRemove all metallic objects & credit cardsLie on flat platform that is moved into narrow tube containing magnet (be able to lay flat for an hour with out moving)Scanning process is painless, but hear thumping of magnetic coils as field is being pulsesMAGNETIC RESONANCE ANGIOGRAPHY (MRA)Uses magnetic fields and 3-dimensional images to look at your vesselsValuable tool for investigating vascular disease, aneurysms, & arteriovenous malformationsDemonstrates patency & adequacy of cerebral circulation ELECTROPHYSIOLOGIC TESTSELEECTROECEPHALOGRPHY– EEGRecord of electrical activity in brain Provides physiologic assessment of cerebral activityUseful for diagnosing seizures (sudden impulses of electrical activity), screening for coma or organic brain syndrome (some forms of dementia) , brain death = no electrical activity. Calm, quite, Indicator of brain deathElectrodes arranged on scalp to record electrical activity (printed out on graph)For baseline – lie quietly with eyes closedMay be asked to hyperventilate for 3-4 minutes & then look at bright flashing lightSleep deprivation is used to record activity.EEG PREP.May be sleep deprived on night before to ↑chances of recording seizure activityTranquilizers & stimulants should be withheld 24-48 hours before testCoffee, tea, chocolate, & cola drinks omitted in meal before test (they are stimulants)Meal is not omitted because altered blood glucose level can change brain wave patterns. Feed the brain.Remove all metalProcedure takes 45 – 60 minutesAssure patient test does not cause electric shockEVOKED POTENTIAL STUDIESEvaluate changes & responses in brain waves recorded from scalp electrodes after introduction of external stimulusVisual evoked responses – flash things in front of you. Pictures or shapes, etc.Auditory evoked responses – headphones, hearing test sounds.Somatosensory evoked responses - No specific prep except reassurance & encouragement of relaxationTests finds delays form pathway to brainMS, polyneuropathy, Gillian Burray – speed of nerve impulse slow down.Metabolic problems change your brain wave activity.ELECTROMYELOGRAPHYMeasures electrical potential of muscles & nerves leading to them by introducing needle electrodes into themInvasiveUseful in determining presence of neuromuscular disorders & myopathies Helps to distinguish weakness due to neuropathy (disease of the nerve)from weakness due to other causesNo special patient prepFrom where you shocked to where its being measuredDiabetics – can have neuropathy NERVE CONDUCTION STUDIESStimulating peripheral nerves at several points along its course & recording muscle action potential or sensory action potentialNon-invasive (technician can do it)Surface or needle electrodes placed on skin over nerve to stimulate nerveUseful in study of peripheral nerve neuropathies MYELOGRAPHYRadiograph of spinal subarachnoid space taken after contrast medium is injected into spinal subarachnoid space through spinal puncture (spinal tap)Enables visualization of vertebral column, intervertebral disks, spinal nerve roots, and blood vesselsUse to see if spinal cord is compromised MYELOGRAPHY POST-OPIf using Isovue, patient lies in bed with HOB ↑15° to 30° to reduce upward dispersionMay be ambulatory or remain in bed as prescribed by physicianIf using oil based medium, patient lies in recumbent (with head down) position for usually 12 to 24 hours to reduce CSF leakageUsually permitted to turn from side to sideBiggest precaution to look for is seizuresLUMBAR PUNCTURE AND CEREBROSPINAL FLUIDInsert needle into lumbar subarachnoid space (usually 3rd & 4th) to withdraw CSF CSFClear, colorless, specific gravity – 1.007 (Meningitis – will cause it to look cloudy)Disease produces changes in compositionLab tests:Cell countCultureGlucose (csf is made up mostly of sugar)ProteinImmunoglobulins Specimen should be sent immediately to laboratory (take it down yourself)CSF in healthy state should have minimal WBCs & no RBCsPurpose:to obtain spinal fluid for examto measure & relieve spinal fluid pressureto determine presence or absence of blood to detect spinal subarachnoid blockto administer antibiotics intrathecally (straight into spinal cord itself) in certain cases of infectionRequires patient to be relaxedStrict aseptic technique is mandatory by all personnelContraindicated in clients with ICP (increased crainial pressure) – brain herniation can occur if done with ICP.Contraindicated in clients with skin infections at or near puncture siteNursing InterventionsReassure patient that needle inserted into spine will not result in paralysisNeeds to empty bladder & bowel before procedurePlaced on side with back toward doctor – lateral with neck, hips, knees flexedMaintain spine in horizontal position (like a mad cat flexed)POST-LP CAREBedrest in flat (HOB flat) position for 4 – 8 hours Encourage fluids(esp. caffeinated fluids) to facilitate CSF productionAdminister analgesics as ordered if headache occursMonitor neurologic signs if LP done to reduce ICPWatch for signs of chemical or bacterial meningitisFever, stiff neck, photophobiaPOST- LP HEADACHERanges from mild to severeLasts a few hours to several daysMore severe when sit or standCaused by leakage of CSF at puncture site that continues to escape into tissues by way of needle tract from spinal canal Depletes CSF in cranium producing tension & stretching when assume upright positionHas sugar and will look thick , with halo sign.Usually managed by bedrest, analgesics, & hydrationOccasionally needs epidural blood patchDoctor withdraws ~ 10 cc patient’s bloodInjects blood to cover (create patch) hole in spinal canal ................
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