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Jane E. Binetti DNP MSN RN Generally part of any overall physical Past Medical History • If neuro problems are suspected: Avoid suggesting what the problem is History of the illness is important for the pt. to recall May not be a reliable historian Medications Surgery or treatments • Cancer therapies Developmental progression Functional ability • ADL’s • Falls Generally, six primary nerve functions are assessed: • Mental status, cranial nerves, motor, sensory, cerebellar function, and reflexes Mental Status reflects functional ability • General appearance • Cognition A and O Language Memory • Mood and affect • 12 Pair • I Olfactory • II Optic • III Oculomotor • IV Trochlear • V Trigeminal • VI Abducens • VII Facial • VIII Acoustic (vestibulocochler) • IX Glossopharangeal • X Vagus • XI Spinal accessory • XII Hypoglossal CN I = Olfactory • Ability to smell • Chronic infections and smoking decrease ability • Aberrancy could be tumor, basilar fracture CN II = Optic • Tests visual fields • One eye at a time • Stare at nose, while identifying peripheral objects • Snellen Eye Chart • Aberrancy lesions on optic nerve or anywhere it tracks through the brain CN III = Oculomotor • Constriction and accommodation • PERRL or PERRLA • Convergence • Ptosis CN IV = Trochlear CN VI = Abducens All are tested together • Follow a finger left/right and up/down • Disconjugate gaze • Nystagmus Oculocephalic reflex: • With eyelids open, turn the head • Normal reflex = eyes move in opposite direction • Abnormal = eyes move with head Oculovestibular reflex: • Cold water test (caloric) V = Trigeminal Nerve • Tested with eyes closed • Sensory with pin • Motor with teeth clenching • Corneal reflex is sensory with V VII = Facial Nerve • Corneal reflex is motor with VII • Blink to threat • Raise brows • Shut eyes tight • Purse lips, smile/frown CN VIII = Acoustic / Vestibulocochlear • Eyes closed, MD uses ticking watch, or whispers a directive • More diagnostic are: Weber: tuning fork for equilateral hearing Rinne: tuning fork for bone vs air conduction Audiometry (ABR) Typically for auditory dysfunction like vertigo or tinnitus CN IX = Glossopharyngeal • Responsible for tongue and swallowing • Palate and uvula should rise CN X = Vagus • Responsible for pharynx, larynx, gi, cardiac, lungs Tested together: both innervate the pharynx • IX reflects sensory piece of Gag reflex • X is motor piece causing retching CN XI = Accessory Nerve • Accessory muscles • Shrug shoulders • Turn your head against resistance CN XII = Hypoglossal Nerve • Stick your tongue out • Midline • Up and down • Side to side against a tongue blade Information on bulk power of muscle, and coordination and balance • Resistance, grasp • Pronator drift • Balance and coordination • Finger to nose testing • Patient should normally have symmetrical strength and motion Hypotonia - flaccid Hypertonia - spastic Myoclonus – muscle spasms Athetosis – slow writhing movements Chorea – involuntary, purposeless Dystonia – impaired tone Patient should be able to discriminate: • Touch with eyes closed • Sharp vs dull • Temperature differences • Vibration • Positional sense Finger placement Romberg test • Cortical sensorium Graphesthesia, stereognosis Tendons attached to skeletal muscles have receptors that will react • Tapped with reflex hammer • Range is 0/5 – 5/5 with 2/5 as “normal” • Arreflexia to hyperreflexia with clonus • Generally Biceps or Patellar reflexes are tested Triceps, Brachioradialis and Achilles may be used Jane E. Binetti DNP RN Common complaint • Can be functional • Often benign but can be key assessment Causes can be intracranial and extracranial Not all cranial tissue is sensitive to pain Based on diagnostic criteria: • Primary headaches include Tension Migraine Cluster headaches • Secondary headaches are caused by: Sinus infections Neck injuries Strokes Medication overuse can also cause headaches A patient can have more than one kind Most common headache reported Gradual onset of band-like tightening Not affected by activity Episodic vs. Chronic – minutes to days Cause • Once thought to be head/neck muscle contraction • EBP suggests neurovascular Abnormal neuron sensitivity Symptoms • No nausea, band like pressure • Photophobia, phonophobia • Palpable neck tension Diagnostics • Patient history Treatment • Typically non-opiod analgesics • ASA or Tylenol Usually unilateral, throbbing, recurring headache Typically related to trigger • Foods • Weather • Stress • Hormones • Fatigue Risk factors: • Most common onset 20-30 • 17% females and 6% males in US • Family history – most have first degree family • Low socioeconomics • Heavy workload • Low education level • Frequent tension headaches IHS Sub Classifications of Migraines • Without Aura Most common type Formally called “common” migraine • With Aura Only about 10% of patients Formally called “classic” migraine Auras are sensory signals • Visual, auditory or motor symptoms Sounds, smells, patterns of light, scotomas, weakness, sensation of movement Prodromes are physical signals • Photophobia • Hyperactivity, irritability • Food cravings Migraine can last hours to days Patients withdraw to quiet, dark places Throbbing pain matches the pulse Some people are incapacitated by them, but others work through them Some feel they worsen over time Done by History Patients may keep diaries to find triggers Neuro exam may be “normal” • Diagnostic tests may not show anything CT and MRI are not routine • Variation of usual symptoms may be cause for secondary causes to be ruled out Mild: • Non opioids usually work well ASA Acetaminophen Ibuprofen Combination meds with caffeine • Other behavioral therapies Moderate to severe: • Triptans are first line therapy • Reduce neurogenic inflammation of vessels Cause vasoconstriction • Best taken preemptively at onset Sumatriptan (Imitrex) Rizatriptan (Maxalt) Zolmitriptan (Zomig) Sumatriptan/Naproxen (Treximet) combination • Watch your cardiac patients! - vasoconstriction Topiramate (Topamax) • Antiseizure drug taken daily as preventative • Can cause seizures if stopped abruptly • Push fluids to avoid calculi • Can cause drowsiness Beta adrenergic blockers: • Propranolol (Inderal) • Atenolol (Tenormin) Alpha adrenergic blockers: • Ergotamine (Ergomar) • Dihydroergotamine (DHE) Analgesic/Anti-inflammatory • Cambia (Diclofenac) Analgesic combinations • Fiorinal (Butalbital/Aspirin/Caffeine) • Fioricet (Butalbital/Acetaminophen/Caffeine) Corticosteroids • Dexamethasone (Decadron) Tricyclics SSRIs Alpha and Beta adrenergic blockers Anti-seizure meds Ca channel blockers Biofeedback Relaxation Cognitive behavioral therapy Rare headache ~ 0.1% of population Exacerbate and remit Cause: • Not clearly known Triggers: ETOH, weather, odors • Trigeminal nerve • Dysfunction of intracranial vessels • Sympathetic nervous system • ? hypothalamus A pt complaining of sharp, stabbing pain Lasts minutes to hours Many a day/many days Cluster is weeks to months long • Sharp head pain: eye, forehead, cheek • Tearing, swelling, pallor, flushing even ptosis Primarily by History Keeping a diary is helpful Other tests done to rule out a more significant cause: • CT, MRI, MRA, LP • R/O tumor, aneurysm, infection, neuro disease Clusters often happen suddenly at night and are brief, meds are little help • Hi flow O2 is helpful 100% at 6-8L for 10 minutes Can repeat after 5 minute breaks Pt at home would need O2 supply Triptans can be useful Prohylactic tx: • Verapamil, lithium, ergotamine, NSAIDS • Intranasal lidocaine spray For refractory Cluster Headaches: • Nerve blocks • Ablation • Percutaneous radiofrequency • Deep brain stimulation • Overuse of analgesics or any meds used for tx can cause rebound • Avoidance of overuse and ensuring slow withdrawal is helpful • Avoidance of triggers •Hunger •Fatigue Help pts: • With life style changes, diet, smoking • Relaxation/distraction/meditation/yoga • Identify and avoid triggers • Management Early identification Compliance with treatment Stress management