Musculoskeletal/Neuro Flashcards
Sample questions for tremors/Parkinson’s Disease
Where is the tremor? How long does it last? How is it treated? What medications are you on? Limitations on ADLs?
Sample questions for parasthesias (pins and needles)
Precipitating factors? How long did it last? How was it treated? Are you on any medications? How often does it occur? Residual symptoms?
Sample questions for nerve injuries, MS, nervous system disease
Precipitating factors? Causation? When was it diagnosed? What are your specific symptoms? How is it treated? How often do flare-ups occur? Residual symptoms?
Sample questions for headaches
Precipitating factors? How long do they last? How are they treated? How often do they occur? Residual symptoms?
Sample questions for psych meds and herbal meds
What are the medications? Why do the take them? How often do you take them? Do they help? What happens if you d/c the med suddenly or forget a dose? Do you have any side effects?
Sample questions for neuromuscular pain
Which joints are affected?
Do you have LBP?
How well is it managed?
What are the precipitating factors for the pain?
What is your normal ROM?
What makes the pain worse? What makes it better?
Sample questions to assess functional capacity?
have you been doing usual work at your job or at home?
have you been participating in your normal activities in the last 6 months?
Sample questions for chronic pain management?
What have you taken? Why did you take it? When/how long did you take it? How effective was the treatment? Do some meds work better than others at treating your pain?
What is a key concept when providing anesthetics to a patient with a neuromuscular disorder?
pay special attention to positioning and always attempt to maintain a normal range of motion!
then DOCUMENT that you did it
When would you asses the temporomandibular joint?
on someone who has RA or pre-existing TMJ
What are abnormal findings during a TMJ assessment?
swelling, pain, decreased motility
What are normal findings during a TMJ assessment?
clicking or popping
How will you assess the TMJ?
place tips of index finger just in front of the tragus and ask patient to open their mouth.
fingertips should drop into the space where the jaw.
ask the patient to open and close jaw, protrude jaw, and slide it side to side.
How can you assess the C-spine?
flexion = touch chin to chest extension = look up at the ceiling rotation = turn head side to side lateral = touch ear to shoulder on each side
How would you assess shoulder ROM?
abduct the arms to shoulder level
raise arms vertically above the head with palms facing each other
place both hands behind neck with elbows out to the side
place both hands on lumbar spine
Why is it important to assess the shoulder joint pre-op?
thoracic outlet syndrome can occur in the prone position –> causes limb ischemia and potential brachial plexus injury
How can you perform an assessment of the elbow joint?
have patient flex and extend forearm
have patient turn palms up and down to assess pronation and supination
When would it be important to complete a hip ROM?
if the patient is going to be positioned in lithotomy
How would you assess hip ROM?
place hand under the patients lumbar spine and ask them to bring their knee to their chest
place hand on patient’s opposite iliac spine and abduct and extend the leg until the patient tells you to stop or when the iliac spine moves
How would you test cranial nerve 1?
olfactory - have patient smell something common and identify it
How would you assess cranial nerve 2?
pupillary reaction to light, accomodation, confrontation
How would you assess cranial nerve 3?
extra ocular movements
How would you assess cranial nerve 4?
extraocular movements
How would you assess cranial nerve 5?
have patient clench teeth and palpate temporal and masseter muscles
check sensation of trigeminal nerve path
check corneal reflex
How could you assess cranial nerve 6?
extra ocular movements
How could you assess cranial nerve 7?
smile/frown, close eyes tightly against resistance, puff out both cheeks,
How can you assess cranial nerve 8?
general impression of the patient should give you an indication of their hearing level but a more comprehensive exam would require tuning forks and other specialized instruments and must be performed by an audiologist
How could you assess cranial nerve 9 and 10?
voice hoarseness, gag reflex (tongue depressor), checking to make sure of symmetrical palatal movement during “aaahhhh”,
How can you assess cranial nerve 12?
ask the patient to move tongue from side to side
How can you assess cranial nerve 11?
have patient elevate shoulders against resistance or turn their head against resistance
List some important dermatome landmarks:
C3 - front of neck C6 - thumb C8 - pinky T4 - nipple T10 - umbilicus L1 - groin L5 - big toe S1 - heel S3 - perianal region
How is muscle strength standardly assessed?
On a scale from 0-5
0: no movement
1: flickr
2: no effort against gravity
3: some effort against gravity
4: some resistance
5: full strength
What nerves are involved in elbow movement?
flexion - C5, C6
extension - C6, C7, C8
What nerves are involved in palmar grip?
C7, C8, T1
What nerves are involved in finger abduction?
C8, T1, ulnar nerve
What nerves are involved in thumb opposition?
C8, T1, median nerve
What nerves are involved in hip joint movement??
flexion and adduction - L2, L3, L4
abduction - L4, L5, S1
extension - S1
What nerves are involved in knee movement?
flexion - L4, L5, S1, S2
extension - L2, L3, L4
What nerves are involved in foot/ankle movement?
dorsiflexion - L4, L5
plantar flexion - S1
What is the GCS?
standardized scale to assess a patient’s LOC
three categories: best eye opening, best motor response, best verbal response (graded 1-4, 1-5, 1-6 respectively)
GCS
What are normal levels of cortisol in a normal person throughout the day? what about during stress?
25 mg normally, but can increase in excess of 100 mg during stress
How do steroids affect a patient during a stress situation?
they blunt normal feedback mechanisms between hypothalamus, pituitary and the hormone. this prevents the body from making endogenous cortisol. during stress, when they require more cortisol, the body is unable to synthesize any and can cause wide swings in BP and HR among other things
Who requires stress steroid dosing?
any patient who has been on steroids for at least a month in the past 6-12 months will need supplementation
What kind of patients are usually on steroids?
autoimmune disease patients, cancer patients, etc.
what kind of difficulties can the CRNA expect if the patient is taking an MAOI?
life threatening interaction between MAOIs and MEPERIDINE or EPHEDRINE as a result of excessive release of catecholamines, causing HTN crisis
What are some specific MAOIs that CRNAs should be aware of?
iproniazid, phenelzine, isocarboxazid, moclobemide, befloxatone, brofaromine, selegiline
What kind of patients might be taking methotrexate?
RA, ankylosing spondylitis, cancer, MS patients
What are the adverse effects of methotrexate?
immunosuppression, anemia, thrombocytopenia, pulmonary toxicity, renal toxicity, hepatic toxicity
What sort of labs/diagnostic studies should the CRNA have on a patient taking methotrexate?
CBC (b/c the drug affects rapidly proliferating cells)
BMP (b/c of renal toxicity)
PFTs and LFTs if the history warrants
What sort of targeted assessment might the CRNA perform on an MS patient?
an immunosuppression assessment because of the drugs that MS patients take
How might the CRNA assess a patient with MS’s immunosuppression?
any recent history of infection or illness? (persistent cough/sore throat)
what are your medications and how often do you take them?
steroids in the past year?
when was your last remission?
triggers for symptoms? (cold/pain/stress)
what was the severity of the symptoms?
What kinds of pre-existing deficits might an MS patient have?
paralysis (assess motor strength)
sensory changes (assess dermatomes)
autonomic dysfunction (assess HR and orthostatics)
visual impairments (check visual reflexes)
seizures (what meds are they on)
emotional disturbances (what meds are they on)
What is a key teaching moment when the CRNA interacts with a patient who has MS?
the patient may experience a relapse of symptoms following the stress of surgery
What should the CRNA document about a patient with GBS?
time course of the disease? (early phase or recovery phase)
precipitating factors?
onset of symptoms?
Knowing the symptoms of GBS, how should the CRNA prepare?
facial paralysis - is the brainstem involved more?
difficulty swallowing -pharyngeal weakness may lead to airway collapse
impaired ventilation - may need to maintain current vent settings
decreased deep tendon reflexes - regional anesthesia and positioning!
extremity paresthesias - careful with positioning
pain - treat ahead of time and manage carefully afterwards
ANS dysfunction - check an ECG and ask about orthostatics, prepare for vasoactive med use
What questions are important to ask a patient who presents with Parkinson’s disease?
Age of symptom onset? recent exacerbations and hospitalizations? current and past symptoms? how long did they last? what helped? temperature regulation issues? dizziness or fainting (orthostatics)? dysphagia/difficulty breathing? pulmonary infection? Hx of peroglide therapy? when do you take your meds?
Why should the CRNA ask about peroglide therapy to a Parkinson’s patient?
it is a discontinued drug r/t mitral and aortic valve problems, so the CRNA may consider ordering an echo to check for valve dysfunction
What medication considerations must the CRNA keep in mind for a Parkinson’s patient?
should continue to take all medications
should be aware of the side effects of all meds
if patient is taking MAOIs, prepare rescue drugs appropriately
if patient is taking anticholinergics, consider dosing NMB more often
maintain levodopa schedule as allowed
What must the CRNA keep in mind when positioning a parkinson’s patient?
they may have contractures and spasticity, so allow for natural range of motion and pad well
Before the physician uses electrocautery….
turn off the DBS in parkinson’s patients
What are some important anesthetic considerations for a patient with LBP or disc herniation?
maintain a natural ROM for positioning and laryngoscopy
assess baseline motor strength and sensory function pre-op
what drugs are they currently on? what helps? what doesn’t help?
are you taking high dose opioids or NSAIDS? (may need to bridge)
consider ordering a CBC/T&S, considering large blood loss is possible
What is the distinction between acute or chronic spinal cord injury that the CRNA must be aware of?
acute patients are at risk for spinal shock (hypotension, loss of reflexes)
chronic patients are at risk for autonomic dysreflexia (HTN crisis, bradycardia)
What pre-op testing might be required for an acute spinal cord injury patient receives an anesthetic?
CBC/type and cross/chem 7 - to assess fluid status
ECG/CXR - to assess for catecholamine induced arrhythmias
vasopressor therapy - for severe hypotension r/t sympathectomy
ventilatory therapy required depending on level of injury
are there associated injuries the CRNA needs to be aware of?
What kind of questions should the CRNA ask a patient with chronic spinal cord injury?
any episodes of autonomic dysreflexia? what relieved it?
do you have old ICU or OR records?
what is the level of injury – may help determine ventilatory reserve and dictate use of opioids
do you have any skin breakdown - carefully position
contractures or spasticity - need to be aware for positioning
What sort of documentation is required before a TIA/CVA patient is given an anesthetic?
what is the history? when did it occur?
residual symptoms?
were the causes of the stroke corrected?
continuation/discontinuation of anticoagulants?
What sort of physical assessments and studies might be helpful when assessing a patient with TIA or CVA?
assess for symptomatic carotid bruit – needs to be assessed 1st and may require a carotid ultrasound
what sort of TIA symptoms have they experience – have they been taken care of?
echo to evaluate valve function and emboli
What questions/assessments are required for a patient with high ICP, head injury or intracranial tumor?
mechanism of injury/illness
location, size, time course of illness/injury
CT or MRI reports/imaging
current LOC
ICP status (associated symptoms? HA, N/V, bradycardia, HTN)
CV status (r/t catecholamine storming?)
cranial nerve dysfunction (may indicate brainstem dysfunction)
muscle strength and sensation
What pre-op/diagnostic studies might be helpful for a neuro injury patient?
endocrine function tests to r/o pituitary involvement
fluid status - r/t use of diuretics
CBC/Chem 7 - blood loss possible
T&S - blood loss possible
ECG - r/t catecholamine storming
echo - to evaluate valve or emboli
CXR/ABG - to evaluate strength of current vent settings
knowledge of baseline vital signs to maintain CPP and CO2 levels
continue current meds like anticonvulsants and steroids
What is an important consideration if a head injury patient is taking an anticonvulsant?
the drugs will induce CYP450 enzymes and may make it difficult to maintain deep plane of anesthesia, may need more frequent dosing of NMB, patient should continue to get these drugs on time, anesthesia may blunt the symptoms of a seizure
What questions should the CRNA ask if the patient has a seizure disorder?
what meds are you on?
type of seizure? length? precipitating factors? recovery period?
hx of status epilepticus? what helped? associated complications?
What tests or other considerations must the CRNA be aware of when caring for a patient with a seizure disorder?
labs such as CBC, platelets, electrolyte panel are common
may need anticonvulsant level if its a new therapy, otherwise ok
cancel case unless seizures are under control as per neurology
What is the main concern when caring for a patient with SLE?
complications associated with the widespread vasculitis may appear or be exacerbated
What specific questions should you assess for in a patient with SLE?
do you exercise? how much? tolerance? do you have a skin rash? where? any difficulty breathing? use of accessory muscles? history of cardiac problems? anemia? hx of reflux or N/V episodes? problems with your kidneys? normal range of motion and any joint/limb pain?
What diagnostic should be considered in a patient with SLE?
chem panel to assess fluid status
CBC and platelets to assess for anemias
PFTs to eval restrictive disease if pulmonary involvement is suspected
echo and cardiac consult if hx of cardiac involvement
pre-op pulse ox, especially if value is difficult to obtain on finger
albumin level and renal function tests to eval renal involvement
Why might a pulse ox reading be difficult to obtain in a patient with SLE?
because vasospastic disease like Raynauds Syndrome is possible and may require pulse ox reading from the ear
What are common meds that SLE patients can be on that would affect their coagulation status?
NSAIDS (ibuprofen, indomethacin)
ASA
Cox-2 inhibitors
DVT preventative therapy like lovenox or heparin
What joints are commonly affected by RA?
knees, elbows, antlanto-axial, shoulder, hands, feet, hips, ankle
What areas should the CRNA pay especially close attention to when assessing an RA patient? why?
TMJ - may make laryngoscopy difficult if limited ROM
atlanto-axial - may make intubation difficult/consider advanced imaging
cricoarytenoid arthritis - make require smaller ETT if hoarse voice, dyspnea, stridor, tenderness
What kinds of diagnostic studies should be ordered in an RA patient? Why?
PFTs/ABG if restrictive lung disease is suspected -often have pulmonary fibrosis and accessory muscle weakness and dyspnea may be the 1st sign of cardiac trouble
echo/ekg - if cardiac involvemment is suspected
blood studies - NSAIDs, ASA, methotrexate all prolong bleeding time and may cause anemia… were they bridged with alternative pain therapies?
What are some special considerations when giving anesthesia to a patient with osteoathritis?
note the natural range of motion, focusing on key areas of patient complaint
ask about medications, what works, what doesn’t, do they do steroid injections, when was the last dose?
What are some special considerations when taking the health history for a myasthenia gravis patient?
note the degree of skeletal muscle weakness so that you can adjust for your neuromuscular blockade appropriately
meds – cholinesterase inhibitors antagonize NMB, steroid use might require a stress dose, immunosuppressive therapy r/t infection risk
What are the special concerns with muscular dystrophy?
you should note progression of the disease, their natural range of motion, and current muscle strength (esp pulmonary)
consider an RSI if they have delayed gastric motility
consider PFTs in the case of severe pulmonary function
echo/ekg if you suspect wasting of the cardiac muscle
What are the special concerns with myasthenic syndrome?
note the degree of skeletal muscle weakness
ask about timing/progression of the disease
medications
What are the special concerns when providing anesthetics to a patient with marfan syndrome?
perform a thorough cardiopulmonary exam – usually an echo to eval valve function, also a high risk for pneumothorax
careful assessment of TMJ
Sample questions for seizure/convulsion/paralysis?
precipitating factors? how long does it last? how was it treated? what medications are you on? are there any residual symptoms?
