Neurological Disorders & Neuro Assessments

• Neurological disorders cover a wide range of conditions affecting the nervous system and its functions. Comprehensive neuro assessments and appropriate care plans are critical for patients experiencing these disorders.

Neuro Assessment

• A neurological assessment includes gathering a thorough history, ideally from the patient. The physical examination encompasses evaluating the level of consciousness, cranial nerves, motor and sensory functions, cerebellar function and reflexes.

Glasgow Coma Scale

• It is a tool to assess a patient's level of consciousness, with scores ranging from 3 (coma) to 15 (fully alert). The Glasgow Coma Scale assesses eye opening ability, verbal responses, and motor responses.
• Scores
• Eye opening (E): 1 (none) to 4 (spontaneous)
• Verbal response (V): 1 (none) to 5 (oriented)
• Motor response (M): 1 (none) to 6 (obeys commands)
• A score of 13-15 indicates minor brain injury, 9-12 indicates moderate brain injury, and 3-8 indicates severe brain injury. It is important to know the patient’s baseline and consider any impacting factors during assessment like medications or restraints.

Pediatric Nursing Tip

• Altered mental status could be due to decreased PaO2 (≤60 mm Hg), increased PaCO2 (>45 mm Hg), low blood pressure, fever (increasing oxygen need by 10% per 1° rise), drugs, or seizures.

Neurological Monitoring of Infants and Children

• Includes assessing pain stimuli response, arousal awareness, cranial nerve function, motor response, posturing, and pupillary response. Bulging fontanelles, scalp vein distention, ataxia, spasticity, and abnormal reflexes also require evaluation. Asymmetrical pupils after head injury is a medical emergency if the patient has an altered mental status (AMS).

Psychosocial Considerations and Age-Related Changes

• Several factors influence patient and family responses like age, general health, social status, history of chronic illness, job, and home responsibilities. Altered social roles and body image issues should also be considered. Age-related changes in nervous system include motor sensory changes and alteration of thermoregulation.

Care of Patients with Neuro Diagnoses

• Disorders can affect cognition, personality, mobility, and the ability to perform activities of daily living.

Case 1 Example

• A 22-year-old presenting with a persistent headache for 2 days requires consideration of differential diagnoses (*meningitis, hemorrhage, migraines, stroke, stress, *head injury, headaches, infection, dehydration, hyper and hypo tension, medication side effects, substance use or abuse). Priority assessments follow the OPQRST framework, especially noting if the headache is sudden and severe. History taking includes LMP, PMH, head, urine, stool, sleep, and eye examination details. Priority interventions include hydration (2 liters), cool compresses, trigger avoidance, and consistent caffeine intake. Outcomes include patient education and keeping a trigger diary.

Headache

• Also referred to as cephalalgia.
• Primary headaches (tension, migraine, cluster) are not associated with an underlying cause, whereas secondary headaches are caused by underlying pathologies like infections or tumors. Approximately 20-40% of the US population experiences headaches. Pathophysiology indicates that headaches result from activation of nociceptors (pain-sensitive nerve endings), sending signals via the trigeminal nerve.
• Clinical manifestations vary:
  • Tension headaches can be episodic (10-15 days a month) or chronic (>15 days a month).
  • Cluster headaches are neurovascular, causing severe pain around the eye.
  • Migraines isolate into phases: premonitory, headache, and postdromal.
• Management includes a headache diary, neurological assessment, and diagnostic testing such as CBC, blood cultures for infection, CRP and ESR for inflammation, and CSF testing to rule out causes.

Primary brain tumors

• Originate in the brain, can be slow growing and benign, or highly malignant and aggressive. Gliomas are inclined to develop along the curved areas, and meningiomas are a common form. Acoustic neuromas are also known as schwannomas, and oligodendrogliomas spread slowly.

Clinical manifestations include

• Dependence on their location, and treatment options include chemotherapy, radiation and craniotomy. Biopsies are performed to sample the tissue. Complications can include intracranial bleeding, cerebral edema, seizures, venous thromboembolism, and increased intracranial pressure.

Seizures

• Epilepsy, a chronic disorder. It is characterized by two seizures, which are unprovoked by an immediately identifiable cause and occur more than 24 hours apart. It may results in behavioral changes.
• Pathophysiology: Unprovoked seizures result from genetic/developmental mutation of synapses/Na channel protein genes causing Na channels to remain partly ajar increasing neuronal excitability of glutamate, or mutations causing GABA activity to be ineffective. Clinical manifestations:
  • Rhythmic jerkiness, loss of consciousness, automatisms, sudden loss of motor tone, and incontinence
  • There may be episodes of daydreaming with no loss of consciousness Diagnosis: Labs, CT or MRI of head, and EEG
• Management may require antiepileptic drugs (AEDs) or anticonvulsants for life.
• Sudden cessation of AEDs can cause status epilepticus.

Pre electroencephalogram testing includes:

• No stimulants
• Do not fast as hypoglycemia can alter results
• Hair and scalp need to be clean
• No sedatives

Pediatric Seizures

• Sudden, intermittent episodes of altered level of consciousness (ALOC) that last seconds to minutes and involve involuntary movements. Intracranial causes: Epilepsy, congenital anomaly, birth injury, infection, trauma, degenerative disease, vascular disorder Extracranial causes: Fever, heart disease, metabolic disorders, hypocalcemia, hypoglycemia, dehydration, malnutrition Toxic causes: Anesthetics, drugs, poisons Common triggering factors: Flashing dark/light patterns, startling movements

Partial Seizures

• Account for 40% of seizures and consciousness may be intact or slightly impaired. During a partial seizure, one may have simple or complex seizure.

Seizures Treatment

Treatment: Aim to determine type, site, or cause of seizures. Use diagnostics, such as CT/MRI/EEG, laboratory tests for poisoning/electrolyte abnormalities, and lumbar puncture for changes/increased pressure or WBCs Drug of choice depends on seizure, but can cause drowsiness. Do not stop medication suddenly to avoid status epilepticus.

Reye Syndrome

• Acute noninflammatory encephalopathy and hepatopathy follows a viral infection in children. There may be a correlation with aspirin use during viral infections. Studies show that stress from viral infections along with a genetic metabolic defect can trigger Reye Syndrome. Toxic cerebral levels can cause manifestations, such as AMS, behavioral changes, seizures, and coma. In children, effortless vomiting and altered behavior or AMS following viral illness is characteristic. Goals include reducing ICP, maintaining a patent airway, cerebral oxygenation, fluid and electrolyte balance, and monitoring for bleeding due to liver dysfunction.

Meningitis

• Risk factors: Dorms, jails, long-term care facilities; age <1 or >60, surgery, trauma, and infection.
• Pathophysiology: Inflammation of the meninges primarily of acute or chronic origin by bacterial, viral, fungal or aseptic.
• Clinical manifestations: Fever, headache, altered mental status, photophobia, chills, nausea, vomiting, and meningeal irritation which includes nuchal rigidity and opisthotonos. Severe cases can lead to an increase in ICP, seizures, syndrome of inappropriate antidiuretic hormone (SIADH) or diabetes insipidus (DI).
• Diagnosis and Management: Antibiotic treatment for 14-21 days. Lumbar puncture (aka spinal tap): assesses CSF parameters (below Cauda Equina). RN role: Check consent, room prep, label sample and assistance during procedure.
• Aftermath: Monitor vitals and neuro checks (CSMTs), bed rest (flat or fetal), increase fluids and monitor for headache, bleeding or brainstem herniation (Cushing Triad).

Encephalitis

• Viral infection transmitted via bodily fluids (HSV I), sexually (HSV II), or vectors. Causes acute inflammation which includes the cerebrum, brainstem, and cerebellum.
• Clinical manifestations: Fever, neurological deficits such as headache, photophobia, phonophobia, nuchal rigidity, and neurological deficits. Diagnosis is done through examination of blood, (LP) CSF, EEG, CT, and MRI scans. Management includes antivirals; acyclovir for herpes or doxycycline for Lyme.

Parkinson's Disease

• Progressive, neurodegenerative disease of the CNS that manifests primarily in motor dysfunction due to loss of dopamine production, is slightly more common in males and starts between 40 and 70 years of age.
• 4 main symptoms are resting tremors, muscle rigidity, bradykinesia, and akinesia with mood, cognitive, and behavioral aberrations.

Progressive Stages

• There are 5 progressive stages. Diagnosis comes at 2 cardinal symptoms with asymmetrical presentations. Management includes drug treatment such as anti-cholinergics (trihexyphenidyl (Artane) and benztropine (Cogentin) to reduce tremors/drooling). Stereotactic pallidotomy involves opening the pallidum.

Alzheimer's Disease

• Dementia affecting memory, thinking, and behavior. Diagnosis is post mortem. Life expectancy 2-20 years. Affects 5.3 million Americans. Early onset can be prior to age 65, progressing rapidly.

Low Back Pain

• Spinal degeneration or stenosis and scoliosis causes pain. 2nd most common neurological ailment.
• Clinical manifestations: Pain may be exacerbated by movement, and spasms may limit mobility.
• Management consists of neurological testing, medication, physical therapy, interventional therapy, or surgery .

Herniated Nucleus Pulposus

• Herniation is a major cause of chronic back pain. Weakening or tearing of the annulus triggers compression. Pt experiences correlated dermatome distribution.
• Management- testing mobility, muscles, strength. The most improve in 1-2 months of physical rest without lifting. The RN can administer medications such as gabapentin, NSAIDs, or sedatives. Lastly, the RN should watch for severe complications post administration of meds.

Multiple Sclerosis (MS)

• Autoimmune. Affects 400,000 people and is more common in women. MS consists of Relapsing-remitting, secondary progressive, progressive relapsing, primary progressive types.
• Pathophysiology: Nerves of the CNS degrade from scarred tissue which forms by demyelination. Stress, fever, fatigue, illness, overexertion, cold/heat may trigger episodes.
• Clinical manifestations: include but are not limited to Numbness, tingling or pain, electric-shock sensations, tremors, and fatigue. Diagnosising is proven difficult via exams. Goal is to speed recovery.

Amyotrophic Lateral Sclerosis(ALS)

• Progressive, fatal CNS disease that is autosomal. Symptoms tend to develop after 50 years. Respiratory failure is common. Pathophysiology: Motor Control are impaired which cause upper and lower motor neurons to degenerate and sensation may be intact. Muscle stiffness and difficulty swallowing are common due to these neuron damages . RN should focus on administering medications and head exams.

Neural Tube Defects

• Caused from failures for the neuro tube to close on the cranial or caudal of the spinal cord. Anencephaly: Absence of a forebraint. Microcephaly - Abnormally small brain. And Spina Bifida (Neural Tube Defects)- Group of CNS disorders . Caused by malformation of the spinal cord.

Spinal Cord Injury

• Most common damage by resulting from hyperFlexion rotation. The resulting to injury is from C3 to L5, causing resulting to a non mobility and sensation. 2 ways to test in Spinal Cord Injury are with/ incomplete injuries and Parasympathetic Nervous System test.

Spinal Cord Tumors

• Primary spinal tumors originates within the CNS that causes damage to the spine to cause neurological and systematic injuries.

Myasthenia Gravis

• Motor/fluctuating disorder that causes muscle fatigue that caused auto immunes. There are 3 types to test for: anti-AChR, musk seronegative Mg, and SNGM. Common symptom is Ptosis and bulba. RN may administer test to assist motor movement's, immune therapy for proper function.

Guillain-Barr´ Sybdrome:

Epidemiology: Often happens due to the GI/Respiratory infections that stems back from common illness such as C.jejune. Main Manifestion: Mediated by immune response of acute lower extremity that causes paralysis and weakness. Support and assess for proper diagnostic.

Bell's Palsy

• Facial Paralysis of CN 7 which control the key facial muscles with pregnant and patients who have flu and herpes.

Trigeminal Neuralgia:

• Also referred to as tic of Douloureux where patients have pain disorder. Patients has has neurological disturbances and are known the have suicidal like tendency. RN should administer ice medication to prevent/sooth pain .

Intracranial Pressure

• Increased from trauma, infection, cerebral hernia cause from tissue injuries. To test for ICP rn can set of interventional methods. Physical interventions: High Fowlers Neurosurgical procedures: hemicraniecftomy.

Head injuries:

• Cause for the need in children , rn needs to watch out of hypoxia from cerebral or blood .RN need to look for signs of any neurological complications that can affect the child , such as mental status.

Hydrocephalus

• Increase Caused by blockage/Obstruction CSF/brain which can affect head size and body posture.

Stroke:

• Caused Disrupts of blood flow in the Brian, causing clots and hemmorage. RN need to watch out for patient speech since Ischemic stroke cause sudden blockage cerebral.RN need to administer measures to prevent complications and watch for speech/hemmogic transformations.