Neurological Assessment and Monitoring

Neurological Assessment

• Accurate neurological assessment requires understanding nervous system anatomy and physiology
• Neurological changes can be rapid and subtle
• Early detection and reporting are critical for positive patient outcomes and prompt intervention
• Patient history is best, but family/friends are needed if the patient is unable
• Physical assessment assesses level of consciousness (LOC), cognitive function, cranial nerves, motor/cerebellar function, and reflexes

Altered Mental Status (AMS)

• Causes include PaO2 fall to 60 mm Hg or below, PaCO2 rise above 45 mm Hg, cerebral hypoxia, fever (1° rise increases oxygen by 10%), drugs, seizures, and increased ICP

Neurological Monitoring in Infants and Children

• Observation includes pain stimuli response, arousal awareness, cranial nerve response, motor response, posturing, pupil response, fontanelle bulging, scalp vein distention, ataxia/spasticity in lower extremities, and Moro/tonic neck with withdrawal reflexes

Factors Influencing Patient and Family Response

• Includes age, health, social status, chronic illness history, prior life experiences, job, home responsibilities, altered social roles, body image issues

Age-Related Changes

• Impacts motor and sensory functions, and thermoregulation

Chronic Neurological Disorders

• Require lifelong management and addressing exacerbations
• These include primary headaches, seizure disorders, Parkinson's, and Alzheimer's

Emergent Neurological Conditions

• Include primary brain tumors, meningitis, and encephalitis
• Can be life-threatening

Primary Headaches

• Not linked to underlying causes
• Major types: tension, migraine, and cluster headaches

Secondary Headaches

• Stem from underlying issues like infections, tumors, vascular problems, medication, or idiopathic factors
• Typically onset suddenly with severe pain.
• Migraine headaches affect 20-40% of the US population

Headache Pathophysiology

• Nociceptors react to triggers, sending signals via the trigeminal nerve (cranial nerve V) to the thalamus

Tension Headaches

• Episodic tension headaches occur 10-15 days per month, lasting 30 minutes to days
• Chronic tension headaches: >15 days a month for 3+ months, more severe than episodic

Cluster Headaches

• Severe, unrelenting, unilateral pain in/around the eye

Migraine Headaches

• Involve premonitory, headache, and postdromal phases

Diagnostic Headache Tests

• Blood tests (CBC, cultures, C-reactive protein, ESR), CSF testing, and imaging (CT, MRI) help rule out causes

Headache Treatments

• Physical therapy can help headaches related to posture, anti-inflammatories can help headaches related to arthritis, and corrective devices can help tension headaches caused by temporomandibular joint dysfunction.
• Resting in a dark, quiet place is beneficial

Preventative Headache Medications

• Topiramate can be taken daily

Abortive Headache Medications

• Triptans and ergotamines can be taken at the onset of pain
• Caffeine may also help

Ergot Alkaloid Medications

• Bind to serotonin receptors on nerve endings, decreasing pain message transmission
• Appear effective during early migraine phases

Headache Complication

• Daily/near-daily OTC use leads to frequent headaches only resolved by stopping medications

Brain Tumor Origins

• Brain cells, meninges, nerves, and glands

Tumor Classification

• Based on cell type and tumor location

Gliomas

• Develop along brain's curved areas, especially frontal lobes
• Grades I and II are slow-growing
• Anaplastic gliomas (grade III) are uncontrolled, lacking differentiation

Meningiomas

• Common brain cancer in 40-70 year olds
• Affect females more than males

Oligodendrogliomas

• Slow-growing tumors, generally in the cerebrum of middle aged patients, that usually do not spread to surrounding tissue
• Arise from the fatty covering that protects nerves

Acoustic Neuromas (CN XIII)

• Slow-growing, benign tumors, generally do not invade other tissue
• Compression on cranial nerves (CN V, CN VII, CN IX, CN X) and tissue (cerebellum and brainstem) can cause severe complications

Clinical Signs of Brain Tumors

• Rapid tumor growth can damage tissue and cause swelling
• Increased ICP signs include papilledema, headache, nausea/vomiting, decreased alertness, cognitive impairment, personality changes, ataxia, hemiparesis, abnormal reflexes, and cranial nerve palsies

Brain Tumor Management

• Chemotherapeutic agents used must cross blood-brain barrier
• Agents include carmustine, lomustine, thiotepa, and high-dose methotrexate

Craniotomy

• Most common procedure for brain tumors
• Section of skull (bone flap) removed for brain access

Complications of Brain Tumors

• Variable risk of intracranial bleeding postoperatively
• Vasogenic edema is the most common cerebral edema, blood-brain barrier becomes permeable
• Seizures may occur
• Increased risk of venous thromboembolism (VTE)
• Increased ICP hampers cerebral blood flow, reducing CPP, and leading to secondary brain injury and herniation

Epilepsy

• Chronic characterized by two unprovoked seizures, not from identifiable cause, over 24 hours

Etiology of Epilepsy

• Speculated to involve genetic mutations of synapses or genes coding for sodium channel proteins
• Neuronal hyperexcitability results from sodium channels being partly ajar or improperly closed
• Another possibility involves ineffective activity of gamma-aminobutyric acid (GABA)

Clinical Manifestations of Epilepsy

• Unilateral, rhythmic muscle movements, automatisms, loss of motor tone, and incontinence

Epilepsy Diagnosis

• Diagnosis of exclusion
• An EEG can detect seizures

Pre-EEG Testing Considerations

• Patients should not fast, as hypoglycemia can alter results
• Hair and scalp need to be clean and free of any products
• No sedatives or stimulants 12-24 hours before test
• Consult provider about stopping antiepileptic medications prior to EEG

Epilepsy Management

• Elderly seizure diagnosis is difficult due to resemblance to age-related conditions
• Antiepileptic drugs (AEDs) usually provide complete control
• Sudden AED cessation can cause status epilepticus

Status Epilepticus

• Seizure activity lasting 5+ minutes or two+ seizures without consciousness recovery
• Can be caused by head trauma, hydrocephalus, drug/alcohol withdrawal, metabolic disturbances, or abrupt anticonvulsant withdrawal

Surgical Epilepsy Management

• Vagal nerve stimulator (VNS), similar to a cardiac pacemaker, provides relief for refractory seizures
• Deep brain stimulation: Electrodes are implanted to release electrical impulses
• Partial corpus callosotomy: Craniotomy severs connections between brain hemispheres

Pediatric Seizures

• Sudden, intermittent episodes of ALOC lasting seconds to minutes
• May include involuntary tonic and clonic movements

Intracranial Seizures Causes

• Epilepsy
• Congenital anomaly
• Birth injury
• Infection
• Trauma
• Degenerative disease
• Vascular disorder

Extracranial Seizures Causes

• Fever
• Heart disease
• Metabolic disorders
• Hypocalcemia
• Hypoglycemia
• Dehydration and malnutrition

Toxic Seizures Causes

• Anesthetics
• Drugs
• Poisons

Common Triggering Factors for Seizures

• Flashing lights
• Startling movements
• Overhydration
• Photosensitivity

Seizures Treatment & Diet Changes:

• Required if anticonvulsants are ineffective
• Ketogenic diet is high in fats, low in carbohydrates, produces ketoacidosis

Seizure Management Education

• Child must become active healthcare team member
• Nurse maintains seizure precautions
• Side rails up, padding around bed, medical ID bracelet, supervision during hazardous play, avoid triggers, medication compliance

Reye Syndrome

• Another medical cause of pediatric neurologic changes
• Acute noninflammatory encephalopathy and hepatopathy after viral infection in children
• May be related to aspirin use during viral illness
• Studies show that a genetic metabolic defect triggers Reye syndrome when the stress of a viral illness produces vomiting and hypoglycemia

Goals of Early Treatment

• Complete recovery, reduced ICP, maintained airway, cerebral oxygenation, fluid/electrolyte balance
• Observe for bleeding due to liver dysfunction
• Discourage aspirin/salicylates for flu-like symptoms
• Parents should read medication labels

Meningitis Risk

• Very young (infants) and those over 60 are more predisposed
• Bacterial infections: Neisseria meningitidis, Streptococcus pneumoniae, and Hemophilus influenzae type b (Hib)
• People in close quarters at greatest risk

Meningitis classification

• Acute or chronic

Acute Meningitis

• Bacterial cause, symptoms in hours-days, CSF pleocytosis (increased white blood cells)

Chronic Meningitis

• Symptoms over weeks-months, lasting >4 weeks

Meningitis Manifestations

• Fever, headache, altered mental status, photophobia, chills, nausea, vomiting
• Meningeal irritation: nuchal rigidity/opisthotonos
• Severe cases: increased ICP, seizures, SIADH or DI

Meningitis Diagnosis

• Lumbar puncture (LP) to assess blood, glucose, infection, pressure in CSF
• RN role: check consent, prepare room/labels, assist/support

After Lumbar Puncture

• Vitals and neuro checks (CSMTs/mental status)
• Bedrest, flat or fetal positioning, increased oral fluids
• Monitor for headache/bleeding/increased ICP (headache, nausea/vomiting, altered mental status, photophobia)
• Monitor brainstem herniation (Cushing Triad)
• Bradycardia, systolic hypertension with wide pulse pressure, irregular then decreased respirations

Encephalitis Epidemiology

• Several thousand cases reported yearly
• Caused by enteroviruses (herpes simplex I/II) and arboviruses (Rabies, Lyme, West Nile, EEE)

Encephalitis Pathophysiology

• Inflammation involves both brain and spinal cord, is called encephalomyelitis

Encephalitis Manifestations

• Infections and neurologic deficits related to brain damage without petechial/purpuric rash

Encephalitis Management

• Acyclovir treats most forms
• Ganciclovir (Cytovene) treats CMV
• Doxycycline for Lyme

Parkinson's Epidemiology

• 1.5-2x more common in males aged 40-70

Parkinson's Pathophysiology

• Progressive, neurodegenerative CNS disease, manifesting primarily in motor dysfunction (idiopathic)
• Environmental toxins, brain injury/tumors, antipsychotics, and genetics may be causes
• Motor system disorder, loss of dopamine-producing cells in substantia nigra of basal ganglia

Parkinson's Manifestations

• Resting tremors, muscle rigidity, bradykinesia (slow movements), akinesia (postural instability)
• Other symptoms: mood, cognitive, and behavioral aberrations
• Stages: unilateral weakness/tremors -> physical disabilities -> slow/shuffling gait

Parkinson's Management

• Pharmacological therapy when symptoms disable patient
• Anticholinergics (trihexyphenidyl, benztropine) for tremors/drooling

Surgical Management

• Stereotactic pallidotomy for PD symptoms, opening pallidum within corpus striatum

Alzheimer's Epidemiology

• 500,000 Americans under 65 have dementia, 40% with Alzheimer's
• Early-onset dementia occurs before 65, progresses rapidly
• Life expectancy: 2-20 years
• 5.3 million Americans have Alzheimer's

Alzheimer's Pathophysiology

• Unclear causes
• Protein fragments develop into neurofibrillary tangles and beta-amyloid neuritic plaques, obstructing cells
• Blocks communication by neurotransmitters reducing communication between nerve cells
• Diagnosis made only at autopsy
• Form of dementia involving gradual loss of brain function

Alzheimer's Manifestations

• Affects memory, thinking, and behavior
• In EARLY AD - there is a decrease in the ability to perform complex tasks and problem solving
• Reality orientation may be effective
• As it progresses, loss of ability to perform multiple or complex tasks and difficulty with problem solving
• In LATE AD - word-finding and naming objects becomes difficult.
• Items are often misplaced.
• The person becomes lost easily.,
• Use Validation therapy to recognize and acknowledge the person's feelings and concerns.
• Set a schedule.
• Limit choices

Alzheimer's Management

• Reality orientation in LATE AD may cause distress

Symptoms Recording

• Presumptive diagnosis based on history and physical examination with symptoms recorded

Alzheimer's Treatment

• Vitamin E, an antioxidant is believed to decreases damage by free radicals and can be used with other medications

Low Back Pain (LBP) Epidemiology

• At least 60-80% of the population will have an episode
• Occurs between 30-50 years, costing $50 billion/year
• 2nd most common neurological ailment
• Equally affects men and women

LBP Pathophysiology

• Spinal degeneration: aging, loss of normal spine structure/function
• Spinal stenosis: constriction of foramina/canals
• Scoliosis and lordosis can also cause pain

LBP Clinical Manifestations

• Decreased flexibility/stamina, constipation

LBP Management

• Physical exam, neurological testing (EMG, nerve conduction, evoked potentials), and imaging (X-rays, CT, MRI, bone scans, myelograms)
• Interventional therapy: nerve blocks with local anesthetics, steroids, and narcotics
• Transcutaneous electrical nerve stimulation: mild impulses block pain signals

Herniated Nucleus Pulposus Epidemiology

• Disks between vertebrae degenerate with age
• Major cause of severe chronic/recurrent back pain

Herniated Nucleus Pulposus Pathophysiology

• Weakening/tear in annulus fibrosus allows nucleus pulposus to bulge. Causes radiculopathy
• Radiculopathy: nerve root compression, numbness/pain in affected extremity, weakness, inability to control motor movement

Herniated Nucleus Pulposus Management

• History and physical, neurological exam to test reflexes, strength, gait, and touch/vibration
• Tests: X-rays, CT scans, MRIs, and CT myelograms
• Medications: NSAIDs, muscle relaxants, sedatives, nerve pain medications

Surgical Options for Herniated Nucleus Pulposus Management

• Laminotomy is a procedure which opens the lamina to decrease pressure on the compressed nerve root or spinal cord
• Microdiskectomy: Disk removal relieve pressure that is performed as a minimally invasive procedure or with a laminectomy
• Artificial disk replacement: surgeons use a manufactured disk
• Spinal fusion: vertebrae are joined together with bone graft (often from pelvis) or metal
• Lumbar fusion: gold standard for patients unresolved by conservative measures.

Multiple Sclerosis (MS) Epidemiology

• Affects more women than men and twice as many Caucasians, family history, immunological factors, and certain viral infections
• Relapsing-remitting: common (twice as many women as men), typically in 20s/30s
• Secondary progressive: relapsing-remitting -> gradual worsening
• Progressive relapsing: gradual worsening with or without recovery
• Primary progressive: gradual progression

Multiple Sclerosis (MS) Presentation

• Autoimmune disease
• 400,000 people have onset between 20-50 yrs
• Affects more women than men

Multiple Sclerosis (MS) Pathophysiology

• Chronic neurological disorder, CNS nerves degenerate, scar tissue buildup (sclerosis/plaques) during demyelination (destruction of myelin sheath)

Multiple Sclerosis (MS) Manifestations

• Inflammation destroys myelin, impairing sensation, movement, and thinking

Multiple Sclerosis (MS) Management

• Based on medication

MS Treatment

• Medications modify the disease (beta interferons, glatiramer, fingolimod, natalizumab, mitoxantrone)
• MRI of brain and spinal cord reveals lesions/plaques
• Aim is to improve speed of recovery, reduce attacks, and slow progression

MS Diagnostics

• No specific test and can be difficult to diagnose
• History, physical, and neurological exam

MS Complications

• Muscle stiffness/spasms, paralysis (often in legs), bladder/bowel/sexual problems, mental status changes, depression, seizures

Amyotrophic Lateral Sclerosis (ALS) Epidemiology

• Most die from respiratory failure within 3-5 years
• 10% of cases are caused by a genetic defect.
• Lou Gehrig's disease, symptoms after age 50
• Prevalence 3.9/100,000 people

Amyotrophic Lateral Sclerosis (ALS) Pathophysiology

• Inability to function
• Muscles gradually weaken, atrophy, and twitch (fasciculation).
• Brain loses ability to initiate and control muscle movement - voluntary muscles affected, causing paralysis, but sensation is intact
• Rapid deadly CNS disease, affects voluntary muscle control
• Both upper and lower neurons degenerate and die

Amyotrophic Lateral Sclerosis (ALS) Manifestations

• Patients must have clinical manifestations of both upper and lower motor neuron damage that cannot be attributed to other causes
• Muscle cramps/stiffness, weakness, slurred speech, difficulty swallowing
• Upper motor neuron damage: spasticity
• Lower motor neuron damage: flaccidity
• Treatment includes medications for symptomatic relief, such as baclofen for muscle cramps, laxatives and stool softeners for constipation, analeptics (CNS stimulants) for fatigue and weakness, and tricyclic depressants

Amyotrophic Lateral Sclerosis (ALS) Diagnosis

• A progressive disease leads to inability to move
• No single test
• CT scan/MRI of neck and head
• Medications for symptomatic relief

Anencephaly

• Severe birth defect, part of brain, skull, and scalp is missing, neural tube defect (NTD)

Microcephaly

• baby's head smaller than expected, brain not developing properly during pregnancy - Rare

Myelodysplasia (Spina Bifida)

• Group of CNS disorders characterized by malformation of the spinal cord
• Two types that include
  • Occulta (hidden)
    • Cystica (Sac or cyst)

Spina Bifida Occulta

• Minor variation of disoder
• Opening is small
• No associated protrusion of structures
• Often undetected
• May have tuft of hair, dimple, lipoma, or discoloration
• Treatment not necessary unless neuromuscular symptoms appear

Spina Bifida Cystica

• Involves Meningocele and meningomyelocele - Sizes range. surgical correction depending in involvement - Meningomyelocele is serious - membranes and spinal cord go through the opening

Sac Rupture

• May have associated paralysis of lower extremities, poor/no control of bladder/bowel
• Hydrocephalus is common
• Habilitation necessary because legs paralyzed, incontinent
• Aims to minimize the child's disability

Nursing Care

• Newborn in incubator
• Sterile dressing/antibiotics to prevent drying of sac
• Prevent injury to sac, maintain sterile environment
• Sac rupture -> subdural hematoma
• Meningitis is possible due to a portal of entry
• Air in sac can cause tension pneumocephalus
• Check sac for tears/leaks, extremities for deformities/movement
• Measure head circumference, observe Fontanelles
• Monitor life-threatening complications

Care to prevent

• Meningitis, pneumonia, UTI
• Potential for latex allergy
• Prevent infection or injury to the sac
• Correct positioning
• Prone on open diaper

Spinal Cord Injury (SCI) Epidemiology

• Direct or indirect injury to cord/surrounding structures
• High-risk activities, nonuse of gear, alcohol/substance use put the patient at a greater risk
• 12,000/year in US and commonly affects young men between 15-35

Spine Injury Types

• Four types of incomplete injury
  • • Central cord
    • Anterior cord
    • Posterior cord
    • Brown-Sequard's Syndrome
  • • Complete spine injury

Spinal Cord Injuries

• Result from concussion, contusion, compression, tearing, laceration, transection, or ischemia
• Complete injury: total loss of motor/sensory function below injury
• Incomplete injury: some function preserved

Central Cord Syndrome

• Most common, hyperextension injury with central cord swelling. Functional motor loss greater in arms, bladder dysfunction, variable loss of sensation

Anterior Cord Syndrome

• Acute anterior compression or disk herniation
• Manifestations: loss of motor function, pain, temperature, crude touch/pressure below injury; preserved proprioception, fine touch/pressure, vibration

Posterior Cord Syndrome

• Manifestations: loss of proprioception, fine touch/pressure, vibration; intact pain, temperature, crude touch/pressure
• Acute compression

Brown-Séquard Syndrome

• Hemisection of spinal cord from penetrating injury
• Ipsilateral loss of motor function, proprioception, vibration
• Contralateral loss of pain and temperature

Cervical Injuries Can Lead to

• Inability to breathe and quadriplegia

Thoracic Injuries

• Results in paraplegia

Lumbar and Sacral Injuries

• Results in decreased control of legs, bowel/bladder function, and sexual function

Sympathetic Nervous System

• Thoracic and Lumbar, Parasympathetic Nervous System – Vagus Nerve and Sacral Nerves

Maintaining Respiratory Function

• Spinal nerves C3,4,5 “Keep the diaphragm alive”, HIGH C-SPINE INJURIES
  • Phrenic nerve (C6) innervates diaphragm
• suppress ability to cough

Halo Traction and Gardner-Wells Tongs

• Used to stabilize c-spine in place

High Cervical Injury Management

• Affects phrenic nerve. Patients on vasoactive medications carefully monitored

Traction and Traction

• Halo traction device to maintain cervical immobilization Gardner-Wells tongs are U-shaped tongs used for spinal traction

Complications for SCI

• Spinal shock
• Neurogenic shock Autonomic dysreflexia

Primary Spinal Tumors

• Originate within the CNS, secondary tumors come from outside CNS

Tumor Presentation

• Results with a loss of motor and sensory function through and abnormal growth

Diagnostics for Spinal Tumors

• If patient has a known primary tumor and develops back pain with deficits, the provider will have a suspicion of a metastatic process and order radiological testing such as CT or MRI.

Options For Treatment

• monitoring,
• radiation
• Chemo

Myasthenia Gravis (MG)

• Acquired autoimmune neuromuscular junction disorder (antibody-mediated)

MG Epidemiology

• Can be worsened or induced by penicillamine
• Can have mild (ocular symptoms) to severe presentation
• Symptoms include ptosis, diplopia, generalized weakness and respiratory involvement

MG Facts

• Anti-AChR antibody present in 80% of MG patients
• MG facts MuSK 10% and no identified antibodies = SNMG 10%

MG Management

• Clinical Assessment and diagnosis tests

Diagnostic tests with MG

Serological tests, electromyography all aid in establishing a diagnosis an assay for AChR antibodies is essential

Medications

• Pyridostigmine is a medication that is a reversible inhibitor of AChE.

Additional Therapies

• Intravenous immunoglobulin • Plasmapheresis Complications

Guillain-Barré Syndrome (GBS),

• • Respiratory or GI infections are common sources • Campylobacter jejuni is most frequent cause

Diagnostics for GBS

• Established diagnostic criteria for GBS include progressive weakness of two or more limbs caused by neuropathy, areflexia, and history of recent viral or bacterial infection.

Bell's Palsy - Idiopathic Facial

Controls paralysis - CN 7 controls the muscles of the face

Trigeminal Neuralgia

• Sudden, usually unilateral, severe, brief, stabbing, recurrent pain - touching the face causes stabbing

ICP

ICP Best described by Monro-Kellie doctrine or hypothesis • The initial approach to the emergency management of increased ICP consists of airway management and therapies to decrease intracranial contents, such as administration of an osmotic diuretic and hyperventilation

Pediatric Head injruies

• Treatment to decreasing volume of brain

Most common by

• An obstruction
• A sequelae of infection
• Perinatal hemorrhage
• Symptoms by site of obstruction and age

ICP

Teaching signs that indicate shunt malfunction may be occurring How to "pump" the shunt

Bulging fontanels or sun setting eyes for symptoms

Intractanial pressure

Symptoms of increased ICP:

• Increased blood pressure Decrease in pulse rate Decrease in respirations High-pitched cry (infants) Bulging fontanelles (infants) Unequal pupil size or response to light Altered mental status Children may exhibit confusion, Poor feeding Headache

The stroke zone

BEFAST- Balance, Eyes, Face, Arm, Speech, Time The abrupt nature of stroke symptom onset led to coining of the term “brain attack” as a tool to raise the level of urgency surrounding stroke

Common ICP manifestations

Bulging Fontanel The soft spots on an infant's skull can appear swollen or bulging due to the increased pressure inside the skull.

• Altered Mental Status: Vomiting: High-Pitched Cry: Changes in Eye Movements:

Hyponatremia

• Complication in patients with SAH, which may be caused by syndrome of inappropriate
• Antidiuretic hormone (SIADH) or by cerebral salt wasting syndrome,

Conssussion

A Concussion is a set of s/s without any findings on CT scan