Download Alterations in Neuroregulation

Neuro Assessment
Megan McClintock, MS, RN
10/27/11
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
Peripheral Nervous
System
Spinal Nerves
ANS
 Sensory fibers
 Motor fibers
 Dermatomes/myotomes

Cranial Nerves
ANS
Sympathetic
 Parasympathetic

Vertebral Column
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
Diagnostic Studies
Lumbar Puncture
Cerebral Angiography
CT
MRI & MRA
PET & SPECT
Myelogram
EEG
EMG
Ultrasound
Headache
Common source of pain
Primary
Tension
 Migraine
 Cluster

Secondary

Symptom of other primary disease process
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
Migraine Headache
Stages of Migraine
Prodrome
Aura (classic
migraine, 10%)
Headache
Resolution
Interval
How do you know it’s 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
Cluster Headaches
Headache Loci
Headache as Symptom
Brain tumor
Trigeminal neuralgia
Tooth impaction
Viral illness
Sinus infection
Subarachnoid
hemorrhage
CO poisoning
Altitude sickness
Arteritis
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
Headache Interventions
Thorough assessment
Daily exercise
Relaxation techniques
Quiet, dimly lit environment
Massage
Moist hot packs
Dietary counseling
Medications
Seizure Disorders
Dysfunctional
neuronal firing in
one or more lobes of
the brain




Frontal
Temporal
Parietal
Occipital
Causes of Seizures
Epilepsy
Brain injury
Infection
Genetic abnormality
Seizures as Symptoms
Hypoxia
Hypoglycemia
Drug & alcohol
withdrawal
Acidosis
Fever
Lupus
Septicemia
Types of Seizures
Classification Frequency
Generalized Tonic-Clonic
Seizures
Simple Partial Seizure
Complex Partial Seizures
Seizure Complications
Status Epilepticus
 Single seizure lasting > 30 minutes
 Repeated seizures without regaining
consciousness in between
Brain consumes 300-500% more glucose and oxygen
Neuronal death occurs with exhaustion
Seizure First Aid
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
Nursing Interventions
Carefully observe and record
Safety during a seizure
Airway
 No restraints
 Nothing in the mouth

Suction, ambu bag, oxygen at bedside
Multiple Sclerosis (MS)
MS Pathophysiology
Unknown trigger stimulates immune
response -> inflammatory response
->myelin sheath damage -> scar/plaque
formation -> nerve impulse interruption
Types of MS
Benign/stable
Relapsing-remitting
Relapsing-progressive
Chronic-progressive
Symptoms
Treatment
ACTH (adrenocorticotropic hormone)
Prednisone
Interferon drugs

Flu-like symptoms, sensitivity to sun
Immunosuppresive drugs
Additional drugs for symptom control
Exercise
Healthy diet
Parkinson’s Disease
Symptoms
Gradual and insidious
Triad of PD
Tremor
 Rigidity
 Bradykinesia (Bradykinesia Video)

Can also have depression, anxiety,
short-term memory probs
Sleep disorders
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
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
Myasthenia Gravis (MG)
MG Assessment
Diagnostic Tests


EMG
Tensilon test (pg
1513)


Myasthenic crisis
Cholinergic crisis
Physical Exam








Progressive muscle
weakness
Fatigue
Speech difficulties
Ocular palsies
Ptosis
Diplopia
Respiratory distress
Cough, gag reflexes
Treatment
Anticholinesterase drugs (Mestinon or
pyridostigmine)
Alternate-day corticosteroids (prednisone)
Immunosuppressants (cyclosporine, Imuran)
Avoid many classes of drugs
Thymectomy
Plasmapheresis
Immunoglobulin G
Nursing Care
Distinguish between myasthenic crisis
and cholinergic crisis
Semisolid foods
Schedule drugs so peak action is at
mealtimes
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
Amyotrophic Lateral
Sclerosis (ALS)
Lou Gehrig’s 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
Huntington’s 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
Alzheimer’s Disease
(AD)
Chronic, progressive, degenerative
Cause is unknown
Findings – amyloid plaques,
neurofibrillary tangles, loss of
connections between cells, cell deaths
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
Treatment
Cholinesterase inhibitors
Namenda (memantine)
Antidepressants
Antipsychotics
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)
Don’t ask why
Judicious use of restraints
Interventions for sundowning
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
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
Nursing Care
Dementia
Delirium
Careful assessment (use MiniMental 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