NR509 Final Chapter 24 Neurological.pdf

▪ neck pain wih bilaeral weakness and pareshesia in boh upper and lower exremies, oen wih urinary requency. Hand clumsiness, palmer pareshesia, and gai changes maybe suble. Neck exion oen exacerbaes sympoms...

▪ neck pain wih bilaeral weakness and pareshesia in boh upper and lower exremies, oen wih urinary requency. Hand clumsiness, palmer pareshesia, and gai changes maybe suble. Neck exion oen exacerbaes sympoms. ▪ Physical signs hyperreexia; Clonus a he wris, knee, or ankle; Exensor planar reexes (posive Babinski signs); and gai disurbances. May also see Lhermie sign: neck exion wih resulng sensaon o elecrical shock radiang down he spine. Conrmaon o cervical myelopahy warrans neck immobilizaon and neurosurgical evaluaon. Chapter 24 Nervous System Techniques o examinaon o When neurologic disease is suspeced, wo complemenary quesons should be addressed hroughou your assessmen. These quesons are no answered separaely, bu ineracvely as you learn abou he paen during he inerview and esablish your neurologic ndings ▪ wha is he locaon o he responsible lesions in he nervous sysem? ▪ wha is he underlying pahophysiology causing he disease? o he nervous sysem can be divided ino he cenral nervous sysem (CNS) and he peripheral nervous sysem (PNS). o Special echniques ▪ meningeal signs make sure here is no injury or racure o he cervical verebrae or cervical cord. This oen requires radiologic evaluaon. Brudzinski’s sign Anaomy o Brain- CNS ▪ he brain has our regions: he cerebrum, he diencephalon, he brainsem, and he cerebellum. Each cerebral hemisphere is subdivided ino ronal, parieal, emporal, and occipial lobes. ▪ The brain consiss o Gray maer and Myelinaed neuronal axons, or whie maer. ▪ Imporan srucures include he basal ganglia, he halamus, he hypohalamus, he brainsem (midbrain, pawns, and medulla), which connecs he corex wih he spinal cord, he recular acvang (arousal) sysem linked o consciousness, and he cerebellum o spinal cord- CNS ▪ he spinal cord exends rom he medulla o he rs or second lumbar verebrae ▪ he spinal cord is divided ino 5 segmens: cervical (C1 o C8), horacic (T1 o T12), lumbar (L1 o L5), sacral (S1 o S5), and Coccygeal. is roos an ou like a horses ail a L1 o L2, he cauda equina. ▪ conains imporan moor and sensory nerve pahways ha exi and ener he cour via anerior and poserior nerve roos and spinal and peripheral nerves. ▪ Mediaes he monosynapc muscle srech reexes.  o Peripheral nervous sysem ▪ he peripheral nervous sysem consiss o he 12 pairs o cranial nerves and he spinal and peripheral nerves. Mos peripheral nerves conain boh moor and sensory bers. ▪ The 12 pairs o cranial nerves emerge rom he cranial vaul hrough skull oramina and canals o srucures in he head and neck. Syncope, dizziness, and lighheadedness o syncope is complee bu emporary loss o consciousness rom decreased cerebral blood ow, commonly called ainng. o Ge a complee descripon o he even including seng and riggers, any warning signs, posion, and duraon. Wha brough on he episode? Could voices be heard while passing ou and in coming o? How rapid was recovery? Were ose in ose slow or as? ▪ Young people wih emoonal sress and warning sympoms o ushing, warmh, or nausea may have vasopressor syncope o slow onse, slow ose. ▪ Consider seizures, neurocardiogenic condions such as vasovagal syncope, posural achycardia syndrome, carod sinus syncope, and orhosac hypoension, arrhyhmias, especially venricular achycardia and Brady arryhmias, oen wih syncope o sudden onse and ose. o Also ask i anyone observed he episode. Wha did he paen look like beore, during, and aer he episode? Wha is here any seizure like movemen o he arms or legs? Any inconnence o he bladder or bowel? ▪ Tonic clonic moor acviy, inconnence, and poscal sae in generalized seizures. Unlike in syncope, ongue bing or bruising o limbs may occur. ▪ Depending on he ype o seizure, here may be loss o consciousness or abnormal eelings, hough processes, and sensaons, including smells, as well as abnormal movemens. Headaches o Tension headache ▪ Common characeriscs locaon is variable, oen described as a pressing or ghening pain, mild o moderae and inensiy. Onse is gradual, duraon is minues o days. ▪ Associaed sympoms, provoking and relieving acors. Somemes phoophobia, phoophobia, nausea absen increased by susained muscle ension, as in driving or yping. Decrease possibly by massage, or relaxaon. o Migraine (wih aura, wihou aura, varians) ▪ common characeriscs locaon is unilaeral in 70% bironal or global and 30% qualiy is hrobbing or aching, variable and severiy, onse is airly rapid, peaks in one o wo hours. Duraon is 4 o 72 hours. ▪ Associaed sympoms, provoking and relieving acors. Nausea, voming, phoophobia, phonophobia, visual auras, moor or as aecng hand or arm, sensory or as. Increased by alcohol, cerain oods, ension, noise, brigh ligh. More common premaurely. Decreased by quie dark room, sleep. o Cluser headache  ▪ Common characeriscs locaon is unilaeral, usually behind or around he eye. Qualiy is deep, connuous, severe pain. Onse abrup, peaks, wihin minues. Duraon is up o hree hours. ▪ associaed sympoms, provoking and relieving acors. Lacrimaon, rhinorrhea, miosis, piosis, eyelid edema, conjuncval inecon. Increased sensiviy o alcohol during some episodes. o analgesic rebound headache ▪ common characeriscs locaon is previous headache paern. Qualiy is variable. Onse is variable. And duraon depends on he prior headache paern. ▪ Associaed sympoms, provoking and relieving acors. Depends on prior headache paern increased by ever, carbon monoxide, hypoxia, wihdrawal o caeine, and oher headache riggers decreased depending on he cause. o Headaches rom eye disorders ▪ common characeriscs locaon around and over he eyes, may radiae o he Occipial area. qualiy is seady and aching and dull. Answer is gradual. Duraon is variable. ▪ Associaed sympoms, provoking and relieving acors. eye ague, sandy sensaon and eyes, redness o he conjuncva. Increased by prolonged use o he eyes, parcularly or close work period decreases by resng he eyes. o acue glaucoma ▪ common characeriscs locaon in and around he eye. Qualiy is seady, aching, and oen severe. Onse is oen rapid. Duraon is variable, may depend on reamen. ▪ Associaed sympoms, provoking and relieving acors. Diminished vision, somemes nausea and voming. Increased somemes by drops ha dilae he pupils. o Headache rom sinusis ▪ Common characeriscs locaon is usually above he eye or over maxillary sinus. Qualiy is aching or hrobbing, variable and severiy, consider possible migraine. Onse is variable. Duraon is oen several hours a a me recurring over days or longer. ▪ associaed sympoms, provoking and relieving acors. Local enderness, nasal congeson, ooh pain, discharge, and ever. Increased by coughing, sneezing, or jarring o he head, decrease by nasal decongesans, and anbiocs. o Meningis ▪ common characeriscs locaon is generalized, qualiy is seady or hrobbing, very severe. Ose is airly rapid. Duraon is variable, usually days.  Fever, s neck, phoophobia, change in menal saus. Can decrease rom immediae anbiocs unl viral versus bacerial cause idened. o Subarachnoid hemorrhage ▪ Locaon is generalized qualiy is severe, he wors headache o my lie. Onse is usually abrup, predominan sympoms may occur. Duraon is variable, usually days. ▪ nausea, voming, possibly loss o consciousness, neck pain, increased rebleeding, increased inracranial pressure, cerebral edema. Decreased by subspecialy reamens. o Brain umor ▪ locaon varies wih he locaon o he umor. Qualiy is aching, seady, variable in inensiy. Onse is variable. Duraon is oen brie. ▪ Increase by coughing, rebleeding, increase inracranial pressure, cerebral edema. Decreased by subspecialy reamens. o Gian cell areris ▪ locaons near he involved arery, oen he emporal, also he occipial, age relaed. Qualiy is hrobbing, generalized, persisen, oen severe. Onse is gradual or rapid. And duraon is variable. ▪ Tenderness o he adjacen scalp, ever and 50%, ague, weigh loss, new headache and 60%, jaw claudicaon in 50%, visual loss or blindness in 15 o 20%, polymyalgia rheumaca and 50%, increased by movemen o neck and shoulders and oen decreased by seroids. o Posconcussion headache ▪ locaon is oen bu no always localized o he injured area. Qualiy is generalized, dull, aching, consan. Onse is wihin wo hours o one o wo days o he injury. Duraon is weeks, monhs, or even years. ▪ Drowsiness, poor concenraon, conusion, memory loss, blurred vision, dizziness, irriabiliy, reslessness, ague. Increased by menal and physical exeron, sraining, sooping, emoonal exciemen, alcohol. Decreased by res. o Crania neuralgia-rigeminal neuralgia ▪ locaon is he cheek, jaws, lips, or gums, rigeminal nerve divisions wo and hree more han one qualiy is shock like, sabbing, burning, severe pain. Onse is abrup, proximal. Duraon each jab las seconds bu reoccurs a inervals o seconds or minues. ▪ Exhauson rom recurren pain. Increased by ouching cerain areas o he lower ace or mouh, chewing, alking, brushing eeh. Decreased by medicaon, neurovascular decompression. Cranial nerve assessmen o I- olacory ▪ sense o smell Tes sense o smell on each side o loss o smell and sinus condions, head rauma, smoking, aging, cocaine use, Parkinson's disease. o II- opc ▪ Vision Assess visual acuiy. Check visual elds. Inspec opc discs. o Blindness, hemianopsia, papilledema, opc arophy, glaucoma o III-oculomoor ▪ pupillary consricon, opening o he eye, mos exraocular movemens. inspec size and shape o pupils. Tes pupillary reacons o ligh. I abnormal, es reacons o near eor. o Blindness, cranial nerve 3 paralysis, onic pupils; Horner syndrome may aec ligh reacons. o IV-Trochlear ▪ downward, inernal roaon o he eye Assess exraocular movemens o Srabismus and binocular diplopia and cranial nerve 3, 4 and six neuropahy. Diplopia in eye muscle disorders rom myashenia gravis, rauma, hyroid ophhalmopahy, And inernuclear ophhalmoplegia, nysagmus o V-rigeminal ▪ Moor-emporal and maseer muscles, laeral perygoids. Palpae he conracons o emporal and masseer muscles. Tes pain and ligh ouch on ace in Ophhalmic, maxillary, and mandibular zones. o moor or sensory loss rom lesions o cranial nerve ve or is higher moor pahways. ▪ Sensory-acial, he nerve has hree divisions; Ophhalmic, maxillary, mandibular. o VI-Abducens ▪ laeral deviaon o he eye o VII-acial ▪ Moor-acial movemens, including hose o acial expression, closing he eye, closing he mouh. Ask he paen o raise boh eyebrows brown, close eyes ghly, show eeh, smile, and pu ou cheeks. ▪ Sensory ase or saly, swee, sour, and bier subsances on anerior 2/3 o ongue; Sensaon rom he ear. o Weakness rom lesion o peripheral nerve, as in bells palsy, or o CNS, as in a sroke. o VIII- acousc and vesbular ▪ The weber es is o deermine which side o he ears is he one ha has hearing loss. ▪ Sound laeralizes o impaired ear. ▪ Room noise is no well heard, deecon o vibraons improves. And unilaeral Sensorineural loss, sound is heard in he good ear where air conducon is greaer han bone conducon. In conducve loss laeralizaon is o he aeced ear where bone conducon is greaer han air conducon. Compare air and bone conducon (rinne es), in sensorineural hearing loss, sound is heard longer hrough air han bone. And conducve loss sound is heard hrough bone longer han air. o IX-Glossopharyngeal  ▪ Moor-pharynx ▪ Sensory-poserior porons o he eardrum and ear canal, he pharynx, and he poserior ongue, including ase A weakened palle or pharynx impairs swallowing Hoarseness and vocal cord paralysis; Nasal voice and paralysis o palae. In unilaeral paralysis, one side o he palle ails o rise and, ogeher wih he uvula, is pulled oward normal side. Deviaed uvula, palaal paralysis in CVA. absen gag reex is oen normal o X-vagus ▪ Moor-palae, pharynx, larynx ▪ Sensory-Pharynx and larynx See glossopharyngeal o XI- spinal accessory ▪ Moor- sernocleidomasoid, upper poron o he rapezius Assess muscles or bulk, and volunary movemens, and srengh o shoulder shrug. o A rophy, asciculaons, weakness sernocleidomasoid muscles, assess srengh as head urns agains your hand. o Weakness o sernocleidomasoid muscle when head urns o opposie side. o XII- hypoglossal ▪ Moor-ongue Lisen o paens arculaon. Inspec he resng ongue. Inspec he proruded ongue. o Dysarhria rom damage o cranial nerve 10 or 12. o Arophy, asciculaons in ALS, polio o in a unilaeral corcal lesion, he proruded ongue deviaes away rom he side o he corcal lesion; In cranial nerve 12 lesion, ongue deviaes o he weak side. Inracranial pressure (ICP) o Papilledema o he opc disc: elevaed ICP causes ino axonal edma along he opc nerve leading o engorgemen and swelling o he opc disc. ▪ Pink, hyperemic, loss o venous pulsaons, disc more visible, disc swollen wih blurred margins, physiologic cup no visible. ▪ Headache, blurred vision, eeling less aler han usual, voming, changes in behavior, weakness or problems wih moving or alking, lack o energy or sleepiness. Cerebrovascular acciden (CVA) o Sroke is a sudden neurologic deci caused by cerebral vascular ischemia in 87% or hemorrhagic in 13%. hemorrhagic srokes maybe inracerebral 10% o all srokes, or subarachnoid 3% o all srokes. o sroke warning signs and sympoms ▪ ace drooping ▪ arm weakness ▪ Speech diculy  ▪ call 911 i someone shows any o hese signs o oher imporan sympoms ▪ sudden numbness or weakness o he leg, arm, or ace, especially on one side o he body. ▪ Sudden conusion or rouble speaking or undersanding speech. ▪ Sudden rouble seeing in one or boh o he eyes. ▪ Sudden rouble walking, dizziness, loss o balance or coordinaon. ▪ Sudden severe headache wih no known cause. Transien ischemic aack (TIA) o Decreased vascular perusion resuls in sudden ocal bu ransien brain dysuncon, Or in permanen neurological decis and sroke, as deermined by neuro diagnosc imaging. Deecng AT A comma in episode o neurologic dysuncon ha resolves wihin 24 hours, is imporan, in he rs hree monhs aer a Tia, subsequen sroke occurs in approximaely 15% o paens. Chapter 25 Children: Infancy through Adolescence Techniques o examinaon o Inans and young children ▪ perorm non disurbing maneuvers early and poenally disressing maneuvers oward he end. For example, palpae he head and neck and ausculae he hear and lungs early; Examine he ears and mouh and palpae he abdomen near he end. I he child repors pain in he area examine ha par las. ▪ Approached he inan gradually, using a oy or objec or disracon. ▪ Perorm as much o he examinaon as possible wih he inan in he parens lap. ▪ Speak soly o he inan or mimic he inan sounds o arac aenon. ▪ I he inan is cranky, make sure he or she is well ed beore proceeding. ▪ Ask a paren abou he inan srengh o elici useul developmenal and parenng inormaon. ▪ Do no expec o do head o oe examinaon in a specic order. Work wih wha he inan gives you and save he mouh and ear examinaon or las. o Older children and adolescens ▪ use he same sequence as wih aduls, excep examine he mos painul areas las. o Apgar score ▪ Score each newborn according o he able a one and ve minues aer birh according o hree poin scale. ▪ i he ve minue score is eigh or more, proceed o a more complee examinaon.