Neuro Assessment and Glasgow Coma Scale

• Neurological disorders require a neuro assessment
• The history is best provided by the patient

Physical Assessment

• Assess Level of consciousness
• Assess Cranial nerves
• Assess Motor and sensory systems
• Assess Cerebellar
• Assess Reflexes

Glasgow Coma Scale

• The Glasgow Coma Scale assesses: Eye Opening, Verbal Response and Motor Response
• Minor Brain Injury is 13-15 points on the Glasgow Coma Scale
• Moderate Brain Injury is 9-12 points on the Glasgow Coma Scale
• Severe Brain Injury is 3-8 points on the Glasgow Coma Scale
• Prior to assessment, know the patient's baseline and impacting factors like sedation, paralytics, intubation, and restraints

Pediatric Nursing Tip

• Causes of Altered Mental Status (AMS) in pediatric patients
• A fall to 60 mm Hg or below of PaO2 causes altered mental status
• A rise above 45 mm Hg of PaCO2 causes altered mental status
• Low blood pressure that causes cerebral hypoxia
• Fever (1° rise in fever increases oxygen need by 10%)
• Drugs, such as sedatives and antiepileptics
• Seizures (i.e., postictal state)
• Increased Intracranial Pressure (ICP)

Neurological Monitoring – Infants and Children

• Pain stimuli response
• Arousal awareness
• Cranial nerve response
• Motor response
• Posturing
• Pupil response of the eyes
• Reassess diligently, presence of asymmetrical pupils after a head injury is a MEDICAL EMERGENCY if they have AMS
• Bulging fontanelles may indicate a neurological disorder
• Scalp vein distention may indicate a neurological disorder
• Ataxia or spasticity of lower extremities may indicate a neurological disorder
• Moro/tonic neck with withdrawal reflexes may indicate a neurological disorder

Psychosocial Considerations & Age-Related Changes

• Patient and family responses are influenced by age, general health, social status, history of chronic illness, previous life experience, job, and home responsibilities
• Disorders can affect social roles and body image issues
• Age-related changes: motor and sensory changes, and alteration of thermoregulation

Care of Patients with Neuro Diagnoses

• Disorders can affect cognition, personality, mobility, and activities of daily living

Case 1

• A 22-year-old female presents to a College student health center complaining of a persistent headache for 2 days
• Consider the following differential diagnoses: meningitis, hemorrhage, migraines, stroke, stress, head injury, headaches, infection, dehydration, hyper/hypo tension, medication side effects, and substance use or abuse
• Priority assessments: OPQRST: sudden severe
• History to take: LMP, PMH, heal, urine, stool, sleep, eye exams, positioning
• Priority interventions: hydration (2 liters), cool compress, avoiding triggers, and consistent caffeine intake
• Goals/Desired outcomes: to avoid triggers and keep a diary

Headache/Cephalalgia

• Primary headaches are not associated with other underlying causes
• Major types include tension, migraine, and cluster headaches
• Secondary headaches are caused by an underlying pathology, such as infection, neoplasms, or vascular issues
• In the United States, 20-40% of the population and 5-9% of males experience migraine headaches
• Twelve to twenty-five percent of females experience migraine headaches
• Headaches result due to a reaction of nociceptors to triggers, sending messages to the thalamus via the trigeminal nerve

Clinical Manifestations

• Chronic daily headaches are experienced by 4% of the population
• Tension headaches are episodic or chronic in nature
• Episodic tension headaches last 30 minutes to several days occurring 10-15 days per month
• Chronic tension headaches are usually more severe occurring +15 days a month over 3 months
• Cluster headaches are considered neurovascular
• Cluster headaches cause Severe, unrelenting pain in and around the eye
• Migraines isolate into phases
• The phases of Migraines include: premonitory, headache, & postdromal phase

Management of Headaches

• Maintain a headache diary
• Complete a neurological assessment
• Perform diagnostic testing: CBC, blood cultures, CRP, ESR, CSF, & imaging

Primary Brain Tumors

• Originate in the brain
• Tumors can be slow-growing and benign or highly malignant and aggressive
• Gliomas incline to develop along curved areas
• Meningiomas are the most common form
• Oligodendrogliomas may be slow-growing/not spread
• Acoustic neuromas are schwannomas
• Clinical manifestations depend on location
• Manage brain tumors with chemotherapy, radiation, and/or craniotomy
• Biopsies of brain masses are performed
• Examine the cells in the sample tissue to give a specific diagnosis

Complications of Primary Brain Tumors

• Intracranial bleeding
• Cerebral edema
• Vasogenic edema
• Seizures (SIDAH holds onto lots of salt and water, causing dilutional hyponatremia)
• Venous thromboembolism
• Increased intracranial pressure

Seizures

• Epilepsy: a chronic disorder characterized by two unprovoked seizures, by an unidentifiable cause, occurring more than 24 hours apart
• Seizures result in a range of manifestations from behavior changes to loss of consciousness
• Two or more unprovoked seizures, at least 24 hours apart
• Cause of unprovoked seizures likely involves the genetic/developmental mutation of synapses & of genes coding for sodium channel proteins
• Sodium channels remain partly open causing increased neuronal hyperexcitability of glutamate
• Mutations include causing ineffective activity of gamma-aminobutyric acid (GABA), the most common neurotransmitter

Clinical Manifestations of Seizures

• Include rhythmic jerkiness of all extremities and loss of consciousness
• automatisms (repetitive unconscious movements like lip smacking, chewing, or swallowing), sudden loss of motor tone, & incontinence
• Episodes of daydreaming and no loss of consciousness

Diagnosis of Seizures

• Labs, CT/MRI of head
• EEG: An EEG can detect seizures, to prep for this test:
• Do not fast
• Hypoglycemia can alter results
• Ensure hair and scalp are clean and free of any products
• No sedatives 12-24 hours prior to test consulting about antiepileptic use
• No stimulants 12-24 hours prior to test

Treatment of Seizures & Epilepsy

• Management of seizures
• Seizures can be difficult to diagnose in the elderly, b/c they resemble other conditions like dementia/Alzheimer’s
• Antiepileptic drugs (AEDs)/anticonvulsants provide complete control
• Lifelong therapy
• Sudden cessation of AEDs can cause status epilepticus
• Sudden, intermittent episodes of ALOC that last seconds-minutes with possible involuntary tonic & clonic movements
• Intracranial causes include epilepsy, congenital anomaly, birth injuries, infection, trauma, degenerative diseases, etc
• Extracranial causes include fever, heart disease, metabolic disorders, hypocalcemia/glycemia, dehydration, & malnutrition

Toxic Causes of Seizures

• Anesthetics, drugs,& poisons
• Triggering factors include flashing lights, startling movements, overhydration, and photosensitivity
• Three distinct phases: Aura and Tonic/clonic seizure
• Partial- Account for 40%, consciousness intact/slightly impaired, w/simple/complex seizures
• Aim to find the seizure type, site, & cause, with multiple techniques

Diagnostic Techniques of Seizures

• CT/MRI and EEG
• Use laboratory tests to check poisonings/electrolyte abnormalities
• Lumbar puncture is used to check changes in color, look for increased opening pressure, increases in WBCs, or low glucose levels
• Drug choices depend on seizure type
• Drowsiness is a common side effect, so take medications daily
• Don't stop drugs without direction to avoid status epilepticus

Reye Syndrome

• Acute inflammatory condition that follows a viral infection with children
• There may be a relationship with aspirin during a viral flu or illness
• Studies indicate that a metabolic deficiency will trigger, causing vomiting and hypoglycemia
• Toxic levels cause cerebral changes: AMS, behavioral changes, seizures, and coma
• In children, effortless vomiting, altered behavior, AMS due to viral illness are characteristics

Treatment of Reye Syndrome

• Can recover completely if treated early
• Reduction of ICP, maintain a patent airway, encourage cerebral oxygenation, and provide fluid/electrolyte balance
• Observe for bleeding as a result of liver dysfunction
• Discourage aspirin and products with salicylates and tell parent to read labels

Meningitis

• Risk Factors include: Dorms, jails, Long-term care, Age (<1, >60), and Surgery, trauma, infection
• Inflammation of the meninges
• Acute/chronic and is caused by bacterial, viral, fungal infection and aseptic meningitis
• Fever, headache, altered mental status, photophobia, chills, nausea, vomiting
• Meningeal irritation includes nuchal rigidity & opisthotonos
• May cause increased ICP, seizures, SIADH or DI
• Treat infection with 14-21 days of antibiotics, and lumbar puncture

Lumbar Puncture (LP)

• Also called spinal tap, assess the blood, glucose, infection, and pressure in CSF (lumbar spine below Cauda Equina)
• RN: check consent, prep room, labels; assist
• Vitals and Neuro checks. Bedrest in FLAT/fetal positioning
• Increase oral fluids monitor headache, bleeding, S/S of increased ICP
• Cushing Triad as a sign of brainstem herniation: bradycardia, systolic hypertension with wide pulse pressure, irregular/decreased respirations
• Meningitis can result from pericarditis & myocarditis; so assess results of an echocardiogram

Encephalitis

• Herpes simplex 1 results in 2 million 20-40ages, sexually transmitted
• Results from bodily fluids and is sexually transmitted
• Arboviruses are vectors and include rabies, Lyme, west Nile
• Acute inflammation of the brain, including the cerebrum, brainstem, and cerebellum
• Fever and neurological deficits related to cord and spinal cord damage
• Headache, photophobia, phonophobia, and nuchal rigidity
• Testing includes: blood, (LP) CSF, EEG, CT, MRI scan, giving antivirals, acyclovir may be a treatment for herpes
• Doxycycline is a treatment for lyme

Parkinson Disease

• Common in males and between ages of 40–70
• The neurodegenerative disease is shown as a progressive motor dysfunction
• Primarily idiopathic, it causes a loss of dopamine-producing cells in the substania nigra of the basal ganglia
• There are 4 symptoms including:
• Resting tremors, muscle rigidity, bradykinesia, & akinesia/ mood, cognitive, & behavioral Aberrations
• There are 5 progressive stages, usually presenting with unexplained unilateral weakness & upper extremity tremors
• In later stages, physical disabilities are noted, slow, shuffling gait, posture instability
• Final stages slow movements, rigidity pronounced, diagnosis after 2 cardinal symptoms from an asymmetrical presentation

Parkinson Disease Management

• Pharmacological is applied, as symptoms become difficult
• Young patients may be given Anticholinergics for tremors & drooling, example like trihexyphenidyl (Artane) & benztropine (Cogentin)
• Stereotactic pallidotomy, opening of pallidum in the corpus striatum to control the PD symptoms
• Burr hole leads to targeted electrical stimulation

Alzheimer Disease

• Life expectancy from 2-20 years, most common and earliest onset before the age of 65
• As the number of AD cases rise, the diagnosis can only be made at autopsy
• Form of dementia, with the gradual loss of brain function
• Impacts Memory, thinking, and behavior
• See forgetfulness, difficulty with language, short-term memory loss
• Loss of cognitive skills, emotional lability, & personality changes
• There is no cure, confirmed by brain examination after death. Several medications and vitamin E can be considered

Low Back Pain

• The second most common neuromusculoskeletal ailment and can include both
• Normal structure lost via spinal degeneration
• Spinal stenosis applies pressure to spinal cord and Scoliosis & Lordosis may have a pain component
• Movement can cause pain and create spasms can limit mobility History assessment plus physical and Neurological testing
• Treatments include medications and therapies for pain/muscle tone
• Intervention includes electrical and surgery
• Herniation of the nucleus pulposus

Epidemiology of Herniated Nucleus Pulposus

• Ages can cause a degenerated disk
• A major cause that can lead pain
• Pathophysiology includes a tear that can cause bulging outside the disks
• Comprised nerves determines the experience of numbness
• Clinically you see pain and pressure with some correlation to some distribution
• Treatment includes a neurological test. Muscle test is used for treatment

Treatment of Herniated Nucleus Pulposus

• Conservative treatment that may last 1-2 months, PT/OT rest without lifting
• Use NSAIDS,muscle suppressants,sedatives
• Gabapentin/Lyrica and more can help with nerve damaged relief
• Complications can include, bladder and saddle anesthesia
• MUST check a patients urinate history prior to leaving the surgery
• Surgical treatment is Laminectomy.microdiscectomy or spinal fusion

Multiple Sclerosis

• Is an autoimmune disease that occurs during the middle stages of life
• There can be 4 types
• A progressive disease where in the immune system there's a scar tissue and plaque formation
• Triggers include fatigue for fever or illness
• You may notice vision and weakness as symptoms, lack of coordination including numbness in limbs and pain
• Management includes there is no treatment
• Use beta interferons, glatiramer as for what's to be expected, monitor brain and spinal cord for tumors

Amyotrophic Lateral Sclerosis

• ALS or Lou Gehrigs affects the upper and lower neutrons
• The CNS disease causes a lot of side effects and can rapidly show
• Muscle cramps, weakness, slur or difficulty in the upper neutron damage
• There is no cure but supportive tools to diagnose such as CT and medications

Neural Tube Defects

• Failure of the neural tube most often caused from the cranial or caudal ends of the spinal cord
• Lack of brain. Abnormal small forebrain with other parts left alone with little care

Spinda Bifida

• CNS problems associated with Malformation of the spinal cord
• Occulta can be a minor disorder or undetected
• Cystic cysts in the midline with Mingocele
• Treatment of folic acid daily
• Surgical and care such as correct position, prevent of injuries and protect skin

Spinal Cord Injuries

• Injures include hyperflexion, compression, rotation and vertical or penetration Injuries
• These impact the spinal mobility with various forms of Sacral nerve
• Cervical injuries result from quadriplegia
• Thoracic result in paraplegia
• Cord has a damage issue to vital signs
• Monitor breathing and fluid treatments
• Use Halo to stabilize

Spinal Card Tumors

• CNS tumors can come from the spine
• There can be vasodilation that leads to low BP
• Monitor what could the problem be after spinal shock and what the issue can be

Myasthenia Gravis

• Fluctuation of muscle skeletal but there can be weakness and fatigue, this motor disorder is autoimmune
• There could be Ocular and Bulbab in the brainstem
• Testings show for Diagnostic or electromyography
• Treatment includes Meds PyRIDostigmine and some Immunoglobin

Plasmapheresis

• Removes antibodies that blocks in AHR
• Is used when a Myasthenic crisis: dry a respiratory failure of viral nature occurs or from antibiotics

Cholinergic crisis

• Is is medicatated anticholinesterase
• For management, administer medications to patients with: Guillian-Barra from G.I causes

Bell’s Palsy

• This paralysis effect the face can be caused from pregancy of Ages of Flu or 15-60
• The treatment of Trigeminal Neuralgia
• Is to touch or trigger areas of concern because they affect facial areas and make it hard to show emotion or have expressions

Critically Ill Neuro Patients

• Care includes injuries of the CNS should be handled properly

Increased Intracranial Pressure

• Brain, tissie ,blood and CSF occupy the skull, which in turn means
• Cerebral herination forms, as well as edema
• This includes intracranial pressure to the catheter to prevent complications

Physical Interventions to Treat Increased Intracranial Pressure

• Elevate bed, eye watch, using GSC scores and a few ICP techniques to help

Traumatic Causes

• Head injuries that cause death of children
• Concussions and responses that can occur
• Hypoxia and Infections can occur
• Be aware of the four steps to take and also use hydrochephalus
• CSF in the vein or brain
• Classifications of Site and Age, and increased headaches which can become increased blood pressure