NEURO.pdf

- Facial: facial expressions & taste (sweet & salt anterior 2/3) CRANIAL NERVES VII- Belspalsy Majority located i...

- Facial: facial expressions & taste (sweet & salt anterior 2/3) CRANIAL NERVES VII- Belspalsy Majority located in brain stem Medulla oblongata - Lowest part of brain VIII - Acoustic/Auditory: hearing - hearing loss, tinnitus, vertigo ; tunning fork 12 CRANIAL NERVES IX - Glossopharyngeal: taste (bitter, posterior 1/3), gag reflex - Absence of posterior taste, dysphagia - Vagus: gag reflex, PNS activation X - Dysphagia ; Tongue depressor I - Olfactory: smell - anosmia XI- Spinal Accessory: neck & shoulder movements - unable to move neck & shoulder II - Optic: vision - blurring of vision/ blindness XII- Hypoglossal: tongue movements - Tongue protrusion/deviations III - Oculomotor: eye movement -Anisocoria (unequal pupils) I I - Trochlear: eye movement IV - Nystagmus (involuntary rapid eye movement) - Trigeminal: Maxillary - sensations, Opthalmic - corneal reflex, V Mandibular – chewing -Trigeminal neurolgia/ ticdouloreux (no sensations, mastication) VI - Abducens: eye movement - Diplopia (double vision)  SPINAL NERVES 3. Inc. RR (bronchodilation) 4. Dry mouth 5. Constipation & urinary retention: FV excess Parasympathetic nervous system (REST & DIGEST) Acetylcholine release Effect: Dec. Body activities; except GIT & bladder Cholinergic/ vagal 1. Constrict pupils (Miosis) 2. Dec. BP & HR 3. Dec. RR (bronchoconstriction) 4. Inc. salivation A - afferent S - sensory 5. Diarrhea & urinary frequency: FV deficit E - efferent M - motor MAJOR DISORDERS AUTONOMIC NERVOUS SYSTEM Increase ICP Sympathetic Nervous system (EMERGENCY) Inc. pressure within the skull Fight or flight response Predisposing factors: Catecholamine release (epinephrine, norepinephrine, dopamine) 1. Stroke (hemorrhage) 2. Tumor From adrenal medulla 3. Inflammation (meningitis, encephalitis) Blood flow inc to heart, brain, lungs & skeletal muscle 4. Trauma Effect: Inc. body activities ; except GIT & bladder 5. Cerebral edema Adrenergic/ anti-cholinergic 6. Hydrocephalus 1. Dilate pupil (mydriasis) Monro kelie hypothesis 2. Inc. HR & BP  Composition of brain & spinal cord: MAP = SBP + (DBP) 2 ÷ 3 1. 80% brain mass PP = systolic – diastolic 2. 10% CSF 3. 10% blood INCREASED ICP MGT: Normal ICP: 0-15 mmHg 1. HOB: semi-fowlers - lung expansion (CI: on spinal injury) EARLY S/SX: Head & neck neutral position - venous drainage 1. Blurred vision, visual acuity, diplopia 2. Evaluate Neuro status q1- 2hrs 2. Change or dec. LOC 3. Airway: check RR (NSG priority) - prepare for intubation & MV Restlessness to confusion Avoid coughing (give antitussive - Vicks formula 44) Disorientation to lethargy Avoid straining of stools, valsava (laxative/ stool softener - 3. Pupillary changes & eye movement problem Docusate sodium (colace) 4. Monoparesis/hemiparesis Avoid excessive vomiting (anri emetic - Ondasetron (zofran) 5. Headache Avoid shivering 4. Drainage: from ears ; sterile dressing, evaluate for s/sx of meningitis LATE S/SX: 5. Safety: seizure precautions; side rail 1. BP inc. 2. Temp inc. MGT ICP: 3. RR. dec. (Irregular , Cheyne stokes: hyperpnea w/ periods of apnea) 1. LIMIT fluid intake - 1.2 L/day 4. Wide pulse pressure 2. Prevent hypoxia - dec. tissue oxygenation & hypercarbia (inc. O2 5. Projectile vomiting retention) 6. Papilledema (edema of optic disk- outer surface of retina) 3. Meds: (same with CVA) 7. Abnormal posturing: a) Corticosteroids: Dexamethasone (Decadron) - dec. Cerebral Decorticate - abnormal flexion edema Decerebrate - abnormal extension b) Osmotic diuretic: Mannitol (osmitrol) - promote cerebral 8. Positive Babinski reflex diuresis by decompressing brain tissue 9. Hemiplegia c) Loop diuretics: Lasix (furosemide) - acts on loop of henle, 6hrs, 10. Seizure GIVE: morning Cerebral perfusion pressure STOKE (CEREBROVASCULAR ACCIDENT) N: 60-100 CPP = MAP-ICP (N: 70-100) Partial or complete disruption of brains body supply  Death of brain cells 4. Kernigs & brudzinski (positive Hemorrhagic stroke) 2 largest & common arteries in stroke 5. Homonymous hemianopsia - loss of half of visual field (mgt: Middle Cerebral Artery (most common) approach UNAFFECTED side) Internal Carotid Artery 6. Unilateral neglect - unaware of paralyzed side existence (mgt: Common in MALE: 2-3x high risk approach AFFECTED side) CAUSE DIAGNOSTICS: 1. Thrombosis - clot (attached) 1. CT scan - to know what stroke type 2. Embolism - dislodged clot - pulmo embolism 2. Cerebral arteriography - site & extent of malocclusion ; allergy test Cerebral Embolism S/SX: 3. MRI - to detect brain tissue damage ; with dye injection a. Headache 4. Carotid UTZ - shows plaque & blood flow of Carotid arteries b. Disorientation 5. Echocardiogram - find clot source in Heart c. Confusion 6. Balance d. Dec. in LOC 3. Hemorrhage - Hemorrhagic stroke Neuro check 4. Compartment syndrome - compression of nerves/arteries GCS (Glasgow coma scale) LOC measurement or quick neuro check S/SX: 1. TIA Warning sign of impending stroke attack: Resolved in 24-72 hrs Facial drooping Inc. ICP Numbness Changes in speech & vision Headache Paresisor plegia (monoplegia 1 extremity) Aphasia Dizziness/ vertigo, tinnitus 2. Stroke in evolution - progression of S/SX of stoke 3. Complete stroke - resolution of stroke ; Cheyne stokes Resp. 3 components of GCS: Unilateral neglect - approach affected 12. Egg crate mattress M - otor response 6 15-14 - conscious (1) 13. MEDS: a. Osmotic diuretic V - erbal response 5 13-11 - Lethargy (2) b. Thrombolytics or fibrinolytic: to dissolve clots/thrombus E - eye opening. 4 10-8 - Stupor (mahirap gisingin) (2) ❖ Urokinase SE: HPN ❖ Streptokinase SE: Pruritus Total= 15 7 - Coma ❖ Tissue plasminogen activator SE: Chest pain 3 - deep coma (lowest score) - Alteplase - Reteplase Mild = 15-13 - Tenecteplase Moderate = 12-9 give within 3-4.5 hrs of onset of signs of CVA Severe = 8-3 ICU - close monitoring Score 8 = intubate CRITERIA: ALWAYS report to physician if GCS is decreasing a. Ct scan - to check for NO bleeding b. NO recent surgery or trauma c. NO pedia > 18 MGT: d. BP controlled if prolonged bleeding --> 3. HOB - low Fowler's 15-30° angle antidote: protamine sulfate 4. Monitor VS, I&O, neuro check 5. AVOID Valsalva maneuver b. Coumadin --> PT (N= 11-12 sec.) --> if prolonged --> antidote: Vit K, 6. Maintain side rails aquamephyton 7. Assist in passive ROM q4 8. Turn client q2h (prevent pneumonia & bed ulcer) 9. NGT (thick fluids) TA aspiration DT dysphagia 15. Platelet aggregation inhibitors: 10. Position - Unaffected side 11. Communication - nonverbal cues, picture board a. Aspirin (PASA) AE: tinnitus Hemianopsia - approach unaffected  b. Clopidogrel (GI discomfort) Carbamazepine - DOC for Trigeminal neuralgia, manic Valproic acid c. Ticlopidine (GI discomfort) Evaluate - type of seizure, duration of post -ictal sleep Safety : SEIZURE protect from injury side rails Abnormal, sudden, excessive discharge don't restrain Seizure: 1st convulsive attack nothing in between teeth Epilepsy: 2nd & with history of seizure turn to side Febrile seizure normal if < 5yrs Give O2 after seizure Pathologic if > 5yrs Avoid alcohol RISK FACTORS: Activities Metabolic imbalances Aura Reduce stimuli Alcohol or drug withdrawal, Autism Remain with client, note time seizure last Genetics Reorient Infection , injuries of brain Priority: SAFETY Cerebral palsy Stress - physical GENERALIZED SEIZURE MGT: a. Tonic-Clonic seizure or Grand-mal (most common) Calm - maintain calm & quite environment 1-3 mins seizure Anticonvulsant: INITIAL SIGN: Phenytoin (Dilantin) 1. Aura stage:  o warning sign of impending seizure attack o Epigastric pain (flashes of lights, noise, taste, smell etc.) o Epileptic cry - fall MAJOR DISORDERS: o loss of consciousness (3-5 mins) o tonic clonic contraction: TONIC (10-20 sec): Body stiffening MULTIPLE SCLEROSIS (many scars) CLONIC: Contraction/jerking 2. Post ictal stage Chronic autoimmune disease that destroys the MYELIN SHEATH of Sleepy, can’t remember, headache neurons in CNS Inflamed neuron b. Patimal Seizure (absence seizure) Dec. Nerve impulse transmission Hallmark: blank stare Women 20-50 y.o dec. eye blinking Relapsing remitting MS pausing amidst conversation IDIOPATHIC loss of consciousness (5-10 secs) most common in children S/SX: c. Status epilepticus 1. Sensory, motor, cognitive problems, Continuous seizure > 5mins 2. Charcot's triad 2 or more seizures w/in 5-minute period A. DYSARTHRIA if untreated leads to coma - death Difficulty/unclear speech PRIORITY: Airway Dt plaque in brainstem DOC : diazepam + dilantin+ D50W * add IV thiamine Interfere with eating, talking & swallowing B. NYSTAGMUS DIAGNOSTICS: Involuntary eye movements 1. CT scan - brain lesion Dt plaque in eye nerves 2. EEG electrocephalography - hyperactive brainwave - shampoo first C. OPTIC NERVE - NOT NPO Blurring of vision (Diplopia, scotoma - blind spots) - NO coffee - stimulant may alter EEG result - NO sleep D. INTENTION TREMORS  Dt plaque in motor pathway: 3. Side rails up ❖ Tremors 4. Turn patient q2h ❖ Ataxis - drunken like movement with loss of balance 5. ROM exercise - to prevent contractures ❖ Muscle weakness & spasm 6. Inc. fluid intake ❖ Paralysis 7. AVOID stress, pregnancy, surgery, overexercise 8. Assist in plasmapheresis 9. MEDICATIONS: for acute exacerbations 3. Plaques In Sensory Pathway Corticosteroids; a. Numbness & paresthesia - dec. Inflammation & prevent paralysis 4. Plaques in ANS - Prednisone a. Urinary retention or incontinence - Dexamethasone b. Constipation Corticotropin: c. Dec. Sexual ability - adrenocorticotropic hormone 5. Higher order activities - best taken AM (coz steriod) a. Cognitive: poor memory, attention, problem solving issue Baclofen (lioresal) - muscle relaxant, to dec. spasticity b. Psychosocial: depression, anxiety, mood swings Dantrolene (dantrium) - muscle relaxant, to dec. spasticity 6. Uhthoff's sign Amantadine - antiviral, antiparkinsonian, helps in fatigue Heat makes symptoms worse Propranolol - beta blocks, for tremors DIAGNOSTIC TEST: 10. For CHRONIC treatment: B interferon - inc. function regulatory T cells (e.g avonex, rebif) 1. CFS analysis via lumbar puncture - inc. CFS protein levels (i.e oligoclonal bands) - means inflammation in CNS 2. MRI (confirmatory) - reveal site & extent of demyelination ALZHEIMER'S DISEASE 3. Lhermitte's Sign - sudden electric like shock sensations - from spine to limb upon bending neck forward Atrophy of brain tissue due to a deficiency os (SANS) somatostatin, acetylcholine, norepinephrine, and substance P. Type of dementia MGT: (supportive & palliative) Cause is idiopathic Sundowners: s/sx worsen in the afternoon or evening 1. Prevent Uhthoff's sign Initial sign: progressive memory loss 2. Assistive devices ❖ Amnesia - anterograde (short term memory loss)  ❖ Agnosia - can't recognize familiar object (stimuli) *how to use* ❖ Anomia - can't recall name familiar every day object (items) SIGNS & SYMPTOMS: ❖ Apraxia - can't perform motor activities ❖ Aphasia: Pill rolling (initial sign) a. Expressive - Broca's aphasia – can understand but can't Progressively, handwriting becomes smaller speak About to fall (stooped posture) - shuffling gait (smooth criminal) b. Receptive - Wernicke's aphasia - can't understand spoken Rigidity - reduced arm swing words (common to Alzheimer's) Hypomimia: masked like facies expressionless Can't swallow/ speak well (drools) - dysphagia, monotonous speech Akinesia: can’t move voluntarily (Freeze up) DIAGNOSTIC TEST: Bradykinesia: Slow movement 1. CT scan - progressive brain atrophy 2. Autopsy (confirmatory) MANAGEMENT: 1. DRUGS: give BEFORE MEALS ; inform patient urine & stool will be dark MANAGEMENT (Supportive & palliative) a. Levodopa & carbidopa (sinemet) - Inc. dopamine 1. DOC: donepezil (aricept) taken at BED TIME b. Amantadine HcI (symmetrel) - controls dyskinesia in long term 2. Provide safe environment use of levodopa 3. Reorient, exercise, reduce stimuli, well-lit room, c. Artate - improve rigidity 2. Resting tremors 3. Keep tremors down with antihistamine 4. Side rails up 5. Turn patient q2h 6. ROM exercise - to prevent contractures PARKINSONS DISEASE 7. Inc. fluid intake, Fiber 8. DIET: Degenerative disease - dec. CHON - AM Common to MALES - Inc. CHON - PM to induce sleep - DT tryptophan - amino acid Cause: Idiopathic 9. Safety precautions: rubber soled shoes, no heels, grab bars Movement disorder, NO weakness 10. Assist in ambulation Dopamine function: control gross voluntary motor 11. Assist in surgery - deep brain stimulation (most common surgical treatment) Decreased dopamine= akinesia, resting tremors, hypertonia  MYASTHENIA GRAVIS MANAGEMENT: 1. Maintain patent airway & adequate ventilation by: Grave/serious muscle weakness = paralysis a. Assist in MV Acetylcholine - muscle contraction b. Monitor pulmonary function test. - dec. vital lung capacity Cholinesterase - breaks acetylcholine to relax muscle 2. Monitor VS, I & O, neuro check 3. Side rails up Chronic, autoimmune disorder impulse transmission at 4. ROM exercise - to prevent contractures neuromuscular junction 5. NGT feeding NO PROBLEM in myelin sheath 6. Assist in plasmapheresis Voluntary muscle 7. Assist in surgery: Thymectomy Common in women 20-40 y.o overtaken by males 60 up 8. MEDICATIONS: Cause: idiopathic Anticholinesterase or Cholinergic - Pyridostigmine (mestinon) - inhibits cholinesterase, leads to SIGNS & SYMPTOMS: Inc. acetylcholine - Neostigmine (prostigmin) 1. Ptosis - drooping of upper eyelid (INITIAL SIGN) Corticosteroids 2. Diplopia - to suppress immune response 3. Mask like facies - Prednisone, Dexamethasone 4. dysarthria Immunosuppressants 5. Dysphagia - Azathioprine 6. Laryngeal muscle weakness - hoarseness - Methotrexate 7. Resp. Muscle weakness - MLT respiratory arrest 8. Leg weakness 9. Monitor for 2 types of crisis: 9. Fatigue a. Myasthenia crisis - cause: Underdose medications, stress, infection - S/sx: Can't see, swallow, breathe DIAGNOSTIC TEST: - Mgt: give Cholinergics agents 1. Tensilon test (edrophonium chloride) b. Cholinergic crisis: - short term (Cholinergic) strengthen muscle for 5-10 mins - cause: overdose of acetylcholinesterase - s/sx: PNS 2. CFS analysis - inc. cholinesterase level Salivation Lacrimation Urination  Defecation expose to recent respiratory or GI infection GI distress Emesis MANAGEMENT: - Mgt: antidote: atropine sulfate 1. Maintain patent airway & adequate ventilation by: -Assist in MV - Monitor pulmonary function test. - dec. vital lung capacity GUILLAN-BARRE SYNDROME 2. Monitor VS, I & O, neuro check 3. ECG Galing Baba Symmetrical 4. Side rails up Autoimmune, acute Acute ascending paralysis due to demyelination, immune system 5. ROM exercise - to prevent contractures attacks MYELIN SHEATH 6. NGT feeding Affected: Men & woman Cause: idiopathic but Recovery is possible 7. Assist in plasmapheresis SIGNS & SYMPTOMS: sensory, motor, ANS dysfunction 8. MEDICATIONS: 1. Clumsiness (Initial sign) Corticosteroids 2. Dec. DTR - to suppress immune response 3. Paresthesia - Prednisone, Dexamethasone 4. Difficulty breathing IV immunoglobulin - to fight GBS antibodies 5. Dysphagia Anti arrythmic agents 6. ANS changes: - Amiodarone a. Alternate HPN to hypotension may lead to arrhythmias - Lidocaine / xylocaine b. Urinary incontinence - Bretylium c. Constipation STROKE (CVA) DIAGNOSTIC TEST: 1. CSF analysis via lumbar puncture 2 types: Inc. CHON (protein) but normal WBC 1. Ischemic stroke: due to embolism or thrombosis 2. Hemorrhagic stroke: Brain aneurysm, uncontrolled HPT, old age D/X: CT SCAN & MRI MGT: 1. TPA (Tissue plasminogen activator): dissolves clot by activating protein causes Fibrinolysis for ISCHEMIC stroke only Given with 3 hrs from onset of S/sx 2. Monitor: V/S, Airway, CN, S/SX: Hemianopsia: loss of half of a visual field Dysphagia: difficulty swallowing Dysarthria: Difficulty speaking Agraphia: loss of ability to write Alexia: loss of ability to read Agnosia: Don’t recognize object or people Aphasia: a. Receptive (Wernicke’s area) Unable to comprehend b. Expressive (Broca’s area) Can comprehend but can’t speak