CNS Flashcards
How should you conduct an H&P for a patient with neurological or musculoskeletal dz?
- Start with general/exclusion questions appropriate to the patient’s risk profile
- If you get a positive response, try to determine real meaning of answer, and ask more specific questions and document response
- Your physical examination should reflect the results of your history taking as well as the standard airway, pulmonary, and cardiac assessments
What are some sample general questions for Neuro and Musculoskelatal patients?
Have you ever had a seizure, stroke, or paralysis?
- Precipitating factors, how long did it last, how was/is it treated (medications, etc.), how often does it occur, residual symptoms
Have you ever been diagnosed as having a tremor or Parkinson’s disease?
- Where is the tremor, how long does it last, how is it treated (medications, etc.), limitations on activities of daily living
Have you ever had numbness, tingling, or “pins-and-needles” in your arm or leg that has lasted more than 2 hours?
- Precipitating factors, how long did it last, how was/is it treated (medications, etc.), how often does it occur, residual symptoms
Have you ever had nerve injury, MS, or any other nervous system disease?
- Precipitating factors, causation?, when was it diagnosed, specific symptoms, how is it treated (medications, etc.), how often does it occur, residual symptoms
Have you ever had migraine headaches?
- Precipitating factors, how long does it last, how is it treated (medications, etc.), how often does it occur, residual symptoms
Have you taken antidepressant, sedative, tranquilizing, anti-seizure, or herbal medications in the last year?
- What medications/herbals were taken and when, how often, last dose? What happens if medications are discontinued suddenly? Does the patient notice any side effects as a result of taking these medications
Have you ever had pains in your joints or low back pain?
- Which joints are affected and what are the precipitating factors (normal range of motion!!!). What makes the pain worse? Does anything relieve the pain?
Have you been working at your usual job or doing your normal activities in the last week, month, year?
- What, when, why?
Have you taken pain pills or had pain shots in the last 6 months?
- What, when ,why? How much? How effective was the treatment? Are their certain agents that work better than others at controlling your pain?
What are the general principles of the anesthetic musculoskeletal assessment?
With the induction of sedation, regional or general anesthesia we take away the normal protective pain reflexes
- Focus on determining range of motion abnormalities & joint integrity (document baseline)
- Maintain natural range of motion for all anesthetic procedures and surgical positioning (document)
What is part of the of the Anesthetic Musculoskeletal assessment?
- Temporomandibular joint
- Cervical spine
- The shoulder girdle
- The shoulder
- The elbow
- The hip
How you assess the Temporomandibular Joint?
- Place tips of index finger just in front of the tragus of ear - ask patient to open mouth.
- Fingertips should drop into joint spaces as mouth opens.
- Check for smooth range of motion, swelling/tenderness.
- Snapping & clicking normal.
- Ask patient to open and close mouth, protrude & retract (jutting the jaw forward), & perform side to side motion.
How do you assess the Cervical Spine?
- Flexion = Touch the chin to the test
- Extension= Look up at the ceiling
- Rotation= Turn the head to each side looking directly over the shoulder
- Lateral Bending = Tilt the head touching ear to shoulder
How do you assess the shoulder girdle?
(adduction, abduction, flexion, extension,
internal & external rotation)
- Abduct the arms to shoulder level.
- Raise arms vertical position above head palms facing each other.
- Place both hands behind the neck with elbows out to the side.
- Place both hands behind the small of the back.
How do you assess the shoulder?
Thoracic Outlet Syndrome- compression of brachial plexus and subclavian vessels near the first rib
- Be certain patient can work or sleep with arms elevated over their head before putting arms beside head (prone positioning)
How do you assess the elbow?
- Ask pt. to bend and straighten elbow (flexion and extension)
- With arms at sides and elbows flexed instruct pt. to turn palms up (supination) and palms down (pronation)
How do you assess the hip?
- Concentrate on ROM that can impact positioning
- Flexion – supine pt. bends each knee to chest/abdomen
- Abduction – supine pt. stabilize anterior superior iliac spine and abduct the extended leg until the iliac spine moves = limit!
What is part of the nervous system assessment?
- Mental status
- Speech
- Cranial nerves
- Gait
- Motor function
- Sensory function
What are the components of the cranial nerve assessment?
- I = Olfactory (smell)
- II = Optic (sight – confrontation test; pupillary reaction to light)
- III = Oculomotor (pupillary reaction to light; extraoccular movements)
- IV = Trochlear (extraoccular movements)
- VI = Abducens (extraoccular movements)
- V= Trigeminal
- Ask the patient to clench his/her teeth as you palpate temporal and massetter muscles
- Check sensation in areas circled to the right
- Corneal reflex (cotton ball)
- VII – Facial
- Ask patient to:
- Raise both eyebrows
- Frown
- Close eyes tightly so you can’t open them
- Show teeth
- Smile
- Puff out both cheeks
- VIII – Acoustic (hearing)
- IX –Glossopharyngeal and X – Vagus (voice hoarseness?, gag reflex, AHH- palate should rise symmetrically)
- XII – Hypoglossal (tongue movement, ask them to move tongue side to side)
- XI = Spinal Accessory
- ask pt. to turn head to each side against your hand
- Ask patient to shrug both shoulders upward against your hand – trapezii strength
How do you assess muscle strength?
How do you Grade muscle strength?
What Spine level are some muscle movements?
Test flexion and extension and compare symmetry
Grade on 0-5 scale
- No muscular contraction detected
- Barely detectable
- Active movement with gravity eliminated
- Active movement against gravity
- Active movement against gravity with some resistance
- Active movement against gravity with full resistance
- Elbow flexion (C5, C6), extension (C6, C7, C8)
- Grip (C7, C8, T1)
- Finger Abduction (C8, T1, ulnar nerve)
- Opposition of the thumb (C8, T1, median nerve)
- Hip Flexion & Adduction (L2, L3, L4)
- Hip Abduction (L4, L5, S1)
- Hip Extension (S1)
- Knee Extension (L2, L3, L4)
- Knee Flexion (L4, L5, S1, S2)
- Dorsiflexion (L4, L5)
- Plantar Flexion (S1)
How do you assess a patient with a head injury?
Glasgow Coma Scale – defines neurologic function impairment
- Eyes open - Never(1)-spontaneous (4)
- Best Verbal Response None (1) – oriented (5)
- Best Motor Response None (1) - obeys commands (6)
Mortality closely related to initial score
Scores 8 or less considered severe (coma)- will require intubation and controlled ventilation for ICP & airway control
What are the anesthetic related implications with steroids?
What are 2 possible steroid reigimen?
- Suppression or disease of the pituitary-adrenal axis will prevent the patient from responding to the stress of surgery appropriately
- Any patient who has received cotricosteroid therapy (suppression of pituitary-adrenal axis) for at least a month in the past 6-12 months needs supplementation
2 possible regimens
- 100mg Hydrocortisone pre-op, intra-op and post-op
- 25 mg Hydrocortisone pre-op + 100mg IV gtt over 12-24 hours
