Neuro Flashcards
Cranial Nerves - 12
I. Olfactory II. Optic III. Oculomotor IV. Trochlear V. Trigeminal VI. Abducens VII. Facial VIII. Acoustic IX. Glossopharyngeal X. Vagus XI. Spinal Accessory XII. Hypoglossal
Hypoglossal CN
XII - tongue movement - motor ; stick out tongue; weakness ? - tongue goes to stronger side
Spinal accessory
sternocleidomastoid and trapezius muscle control - neck strength and shoulder shrug (against resistance) - motor ;
Glossopharyngeal + Vagus
gag, swallow, and cough reflexes; voice quality; vagal parasympathetic response - both
Acoustic
hearing and balance - sensory ; test by whispering
Facial CN
VII - anterior taste buds + facial muscles - both
Trigeminal
motor function of temporal and jaw muscles ; sensory on face - both
Oculomotor + Tronchlear + Abducens
ocular muscle movement - motor - PEARLA
Optic
visual acuity - sensory ; Snellen chart
Olfactory
smell - sensory
CNS consists of …
- Brain - cerebrum, cerebellum, brain stem 2. Spinal cord
PNS consists of …
- 31 pairs of spinal nerves 2. 12 pairs of cranial 3. Autonomic NS
Autonomic NS consists of …
- Sympathetic NS - speeds ; anticholinergic 2. Parasympathetic NS - slows; cholinergic - responsible for involuntary movement of smooth muscles present in GI tract, urinary tract and lungs
Flexed arms, extended legs, plantar flexion, internal rotation of limbs and feet - “toward the cord” - affecting cortical area of brain
Decorticate posturing
Extended arms and legs, plantar flexion, external rotations of limbs and feet; dysfunction in the brainstem area
Decerebrate posturing
No motor function or response
Flaccid
White fiber tracts that connect the neurons in the brain and spinal cord ; only one … attached to each neuron ( can extend down the entire spinal cord)
Axon
A white, lipid covering many axons; white matter; … axons have gaps called nodes of Ranvier - play a major role in impulse conduction
Myelin sheath
Autoimmune disease; characterized by inflammatory response that results in diffuse random or patchy areas of plaque in the white matter of the CNS - myelin sheath is damaged (demyelinated) - impulses still transmitted but not as effective; over time can become completely blocked.
Multiple Sclerosis - pathophysiology
MS: Classification
- Benign MS - 1-2 attacks - complete recovery 2. Relapsing Remitting MS - most common - relapses with partial or full recovery - no progression between attacks 3. Secondary Progressive MS - follows RRMS in 50 % - progressive disability 4. Primary Progressive MS - steady slow progression ; uncommon; little tx available 5. Progressive Relapsing MS - progressive + flare ups ; rare
MS: 1.axons of the nerve remains intact - … 2. both myelin and axon are destroyed - …
- Pt. will regain all function and sensation during remission 2. Permanent loss of motor and sensory function
MS: Etiology
- Autoimmune - following stress 2. Viral 3. Familial tendency 4. Cold climates 5. Females - 15-50 (20-40)
MS: S/s
- Visual disturbances 2. Internuclear opthalmoplegia - abducting eye ( to the side) - nystagmus 3. Sensory sensations - tingling, numbness… 4. Unusual clumsiness, extremity weakness, leg dragging … 5. All symptoms intensified by hyperthermia 6. Lhermitte’s sign - flex neck - electrical sensation - down the back - into legs
MS: Visual problems
- Nystagmus - involuntary rapid eye movement 2. Diplopia - double vision 3. Blurry vision 4. Scotoma - patchy blindness
MS: TX - medications
- Corticosteroids - exacerbation 2. Immunomodulators - for life to slow or stop 3. immunosuppresant agent
Immunosuppresant agent; tx of MS; anticancer; lifetime limit of 8-12 doses - or cardiac damage occurs; shuts down part of immune system causing MS.
Mitoxantrone hydrochloride ( Novantrone)
- Avonex 2. Betaseron 3. Copaxone
Immunomodulators - tx of relapsing-remitting MS ; remission therapy
- drug of choice; IM/weekly
- sub-q daily or 3x’s weekly SE: flue like S/s - decrease in 3 mo; nightmares
- acts like decoy; subcut/daily ; SE: skin decubiti; chest pain (like MI)
Bethanechol (Urecholine)
Cholinergic agent - parasympathomimetic ; MS: treat flaccid bladder; neurologic bladder (incontinence)
Oxybutynin Chloride (Ditropan)
Anticholinergic (cholinergic blocker; parasympathetic depressant) - tx spastic bladder - MS
- Baclofen 2. Flexeril 3. Robaxin 4. Zanaflex
CNS depressant; sympathetic depressant; treat muscle spasticity + spasms
Dandrolene (Dantrium)
CNS direct acting (peripheral) - treat muscle spasticity
Decubiti
pressure sore or bed sore - A pressure-induced ulceration of the skin occurring in persons confined to bed for long periods of time
- Decadrone (Dexamethasone) 2. Methylprednisolone (Solu-Medrol)
Corticosteroids
Reticular activating system
special cells throughout the brainstem - control awareness + alertness ; the reticular formation are has many connections with the cerebrum, the rest of the brainstem and the cerebellum
Caloric test
ice/warm water is forced into ear canal - eyes rotate to opposite/same side of head (Nystagmus) ; performed to evaluate the vestibular (inner ear) portion of auditory nerve ; helps to determine brain death.
Obtunded
awakes only momentarily; confused
Persistent Vegetative State
awake, but unaware of surroundings
Locked-in syndrome
due to brain stem damage - awake and alert , but unable to move or respond, except by blinking eyes; death due to respiratory distress
Light vs deep coma
unresponsive, except to painful stimuli vs unresponsive
Brain stem consists of
Midbrain Pons Medulla
connects brain stem and cerebrum
Midbrain
bridges the two halves of the cerebellum to the medulla and cerebrum
Pons
site of reflex centers for many vital functions, i.e.: • respiratory • cardiac • vasomotor
Medulla
The NS is composed of two types of cells
- Neurons 2. Neuroglial cells - support, nourishment, and protection for neurons
Neuroglial cells - types
- Astrocytes 2. Oligodendroglia 3. Ependymal cells 4. Microglia
A tumor that arises from cells that comprise the supporting tissue of the nervous system; Malignant !!!
Gliomas
Pituitary adenoma types : Benign !!!
- Prolacting secreting - Galacterhea (milk production)
- ACTH secreting - Cushings syndrome (increase in corticosteroids)
- Growth hormone secreting
controls the hormones released by the adrenal gland that support blood pressure, metabolism, and the body’s response to stress
Adrenocorticotrophic hormone (ACTH)
Transphenoidal micro surgical approach
through the nasal passage, going along the septum - then through the sphenoid sinus cavity located deep above the back of the throat to the pituitary gland immediately behind it; tx of pituitary adenoma; Mustache dressing - nose is packed - prevent sneezing ( increase ICP).
Tumor of the 8th CN, can grow quite large; always benign; S/s - vertigo + ringing in the ears (tinnitus) + staggering gait
Acoustic neuroma
Tumor - mass of blood vessels usually congenital ; risk for hemorrhagic stroke; benign
Angioma
Benign, highly vascular tumors which originate in the meningeal layer
Meningioma
Infratentorial tumor - craniotomy - positioning ; + cervical fx
Bed flat with small pillow for pt.
Hydrocephalus - increased CSF related to obstraction of the flow of CSF or displacement of the lateral ventricles by the expending lesions - increased ICP - S/s and TX
S/s : 1. gait disturbance 2. incontinence 3. confusion
TX: Ventriculoperitoneal or ventricular jugular shunt
Halo sign
red stain of blood surrounded with yellow “halo” stain, which is CSF. Need to test with a glucose strip to ensure this is what stain is showing - then call doctor
S/s of increased ICP
- Headache 2. Deteriorating LOC 3. Restlessness 4. Irritability 5. Dilated or pinpoint pupils that are slow to react or nonreactive to light
DI - diabetes insipidus
failure of posterior pituitary gland to release ADH - failure of renal tubules to reabsorb water - urine output is increased (polyuria) - dehydration ( polydipsia) , hypovolemic shock ; Hypernatremia
Vasopressin (Pitressin) - IV
Desmopressin acetate (DDAVP) - IV or nasal spray
antidiuretic hormone; tx of diabetes insipidus
SIADH
syndrome of inappropriate ADH - posterior pituitary gland releases too much ADH - water retention - loss of thirst, weight gain, muscle weakness, decreased LOC; Hyponatremia (dilutional)
- Epidural - between skull and dura - least invasive - least accurate
- Subarachnoid screw - CSF flows - small sample - cannot drain CSF
- Intraventricular - most invasive - most accurate (transducer) - can drain CSF if ICP is elevated
ICP monitoring devices
- Brudzinski’s sign 2. Kernig’s sign
- Severe neck stiffness causes a patient’s hips and knees to flex when the neck is flexed. 2. Severe stiffness of the hamstrings causes an inability to straighten the leg when the hip is flexed to 90 degrees.
The spinal cord is composed of 31 pairs of spinal nerves:
• 8 cervical • 12 thoracic • 5 lumbar • 5 sacral • 1 coccygeal
Dorsal root
Posterior. Contains the sensory portion; afferent in nature (from the body inward to the cord). Part of the body picks up a sensory stimulus which travels ↑ cord to the brain.
Ventral root
Anterior. Is efferent in nature. Impulses travel outward from the brain ↓ cord → body. Contains the motor portion.
UMN lesions
- Loss of voluntary movements;
- Tense muscles - increased tone
- Spastic muscles
- Hyperactive reflexes
LMN lesions
- Loss of voluntary movements
- Decreased muscle tone
- Muscle atrophy
- Absent or dimished reflexes
Autoimmune disease; loss of motor neurons in the anterior (ventral) horns of the spinal cord + motor nuclei of the lower brain stem - muscle atrophy - both upper and lower motor neurons ; death due to respiratory failure; bowel and bladder are not affected - pt remains continent
Amyotropic Lateral Sclerosis (ALS) - Lou Gehrig’s Disease
Riluzole (Rilutek)
tx of ALS - slows progression of the disease
Brain injury; Jarring of the brain-possibly microscopic hemorrhages; closed injury; mild; up to 5 min ( neurological s/s) to 48 hours (headache + N/V); tx: unconscious 5 min - hospital for observation.
Concussion
Brain injury; brain is bruised; loss of consciousness > 24 hrs; 60 % behavioral changes; may recover completely.
Contusion
Skull fractures types
- Open - depressed ( corrective sx) & non-depressed; basilar 2. Closed - coup/ contre coup
Open skull fracture - Basilar
base of the skull; CSF leakage; motorcycle accidents; swelling may affect brain stem; Battles sign
Battles sign
a palpable bogginess of the area behind the ear that may indicate a fracture of a bone of the lower skull; basilar skull fracture
Intracranial hemorrhages
- Epidural 2. Subdural 3. Subarachnoid - due to blunt trauma, aneurysm 4. Intracerebral
Bleeding between the inner skull and the dura; compression of surrounding tissue; due to head trauma; EMERGENCY- bleeding from meningeal artery; loss consciousness - lucid - changes in MS - coma - death; tx: burr hole opening to evacuate blood + repair the artery
Epidural hemorrhage
Bleeding between dural membrane and arachnoid membrane; venous in origin - s/s develop more slowly; 48 hrs-2 weeks; tx: surgical burr hole;
Subdural hemorrhage
Bleeding withing the brain tissue; due to head injury, hypertension, diseases that reduce platelets (ITP, leukemia); nothing can be done; < 5-10 ml - may be reabsorbed without consequences
Intracerebral bleed
The wall of a cerebral artery or vein weakens, dilates and forms a sac - ruptured - subarachnoid bleed ; common - Berry aneurysm ( Circle of Willis); - after rupture - cerebral vasospasm + increase in ICP; dx: cerebral angiography
Cerebral aneurysm
Osmotic diuretic - pulling fluid from brain tissue into vasculature ; used to tx increased ICP ; most effective given IV boluses ( filter needle) ; + Lasix ( to help to pee it out) ; Monitor: I&O, serum electrolytes + serum osmolarity; Assess increase in urinary output and decrease in ICP
Mannitol
An infection by bacteria that have origin in another part of body (sinus, ear or teeth); tx: antibiotics; dx: CSF positive for bacteria (strep or staph) ; CT - abnormal tissue density; EEG: abnormal.
Brain abscess
An inflammation of the brain tissue with no purulent exudate; caused by mosquitoes (west nile); ticks; vaccines; Tx; supportive; antiviral meds; dx: WBC elevated (lymphocytes)
Encephalitis
An acute infection of the meninges - arachnoid and pia mater; types: bacterial, viral ( after chickenpox, mumps) and fungul (AIDS pts)
Meningitis
Most dangerous, contagious and deadly type of meningitis ???
Meningococcal ( Neisseria) - spreads by secretions; often presents with rash and petechiae - often kills within hours of onset
- Ergotamine + Caffeine (Cafergot) 2. Ergotamine tartate (Ergostat) 3. Dihydroergotamine mesylate (Migranal) 4. Methysergite maleate (Sansert)
Ergotamines - tx migraines - activating serotonin receptors - vasoconstriction - abortive therapy
Triptans
Abortive therapy - migraines - activating serotonin receptors - vasoconstriction ; SE: actual or suspected cardiovascular diseases - risk for coronary vasospasm ; Use contraception; Don’t take with SSRI and St. John’s wort (tx of depression) SE: flushing, tingling, hot sensations.
Autoimmune response to a viral infection or vaccines; T cells attack and destroy myelin of the PNS (Schwann cells); initial 2 we; plateau 2 we; recovery 2 ye; Complication - loss of respiratory function
Guillain-Barre Syndrome
Bell’s Palsy
facial paralysis; VII CN - facial ; rapid onset; lasts 3-5 weeks; Inflammation causes pressure on the nerve which is in a snug channel; S/s - like stroke - one side of the face is paralyzed; tx: steroids; pain meds; eye care ( manually close); facial exercise and massage
Trigeminal neuralgia
motor function of temporal and jaw muscles ; sensory on face - both ; pain provoked by movement and stimulation : brushing teeth, chewing, washing face; due to inflammation? or pressure on the nerve ? tx: seizures meds: blood levels drawn for therapeutic range.
Glascow Coma Scale
Sympathetic NS vs Parasympathetic NS
Changes in vital signs ( low BP & HR) due to impaired communication between upper and lower motor neurons; - impaired sympathetic NS activity - massive vasodialation (low BP) - unoposed parasympathetic NS (low HR) - Emergency - low BP - low perfusion to injured cord - no O2 - edema & ischemia increase ;
Neurogenic shock - complication of spinal cord injuries
Neurogenic shock - TX
- Volume expanders ( Dextran )
- Dopamine - to vasoconstrict
- Elevate legs , sequentials , abdominal binder
Unconscious pt must never be placed on their …
backs - danger of aspiration !!!
Interventional neurosurgery - repairing aneurysms - coil or glue procedure - Post op care
- Keep pt on his back with HOB at or below 30 degrees
- Keep affected leg straight (femoral arterial sheath) - 6 hrs after sheath is removed
- Pain meds
- Monitor site for bleeding or hematoma - 5 Ps
- Assess neurological status
- Urine output
- Check BS - if pt is on Decadron (steroid)
- Coil - heparin post op; aspirin for life
- Glue - MAP < 90 - antihypertensives
Demyelination of the peripheral nerves ( they regenerate ) - ascending paralysis ( lower limbs before upper) - muscle weakness + paralysis; causes unknown - post viral ? vaccination ?; Pt. can recover fully ( 1 year) or have long standing neurological deficits
Guillain - Barre Syndrome
Plasmaphoresis and Guillain-Barre Syndrome
removes circulating antibodies thought to be responsible for the disease - plasma is selectively separated from whole blood - blood cells returned to the pt without the plasma - plasma replaces itself or albumin (colloid) is given ; should be done within several days after the onset of the illness
Plasmapheresis - Complications + Nursing Interventions
Disease that affects the trigeminal - V CN; - sensory branch to face and scalp ; Main issue - Pain; TX: Antiseizure meds (Neurontin) - tx nerve pain.
Trigeminal Neuralgia
Acute paralysis of CN VII but may also affect CN V ; motor part - Ptosis ( drooping) - can’t close the eye completely - risk for corneal abrasion or dry eye - lybricate patch at night ; sensory part - Pain ; Usually recover within a few weeks
Bell’s Palsy - Facial paralysis
Migranes - Preventive medications - 2 migranes / week
- Beta-blockers - Inderal
- Tricyclic antidepressants - Elavil & Tofranil
- Antiseizure - Depakote, Neurontin
- Ergotamines - Migranal
Migranes - Abortive medications
- Acetaminophen / NSAIDs; Excedrin ( acetam. + aspirin + caffeine )
- Ergotamines - Cafergot
- Triptans - Imitrex
Ergotamines + Triptans - !!! Caution
Vasoconstrict - use with caution in pts with hx of CAD, angina, PVD
Autoimmune disorder causing a decrease in the neurotransmitter acetylcholine at the neuromascular synaptic junction ; mainly affects face and eyes (muscles intervated by the cranial nerves)- drooping, difficulty chewing; dysphasia; dysarthria; weakness; trouble with secretions ; affects skeletal and respiratory muscles as well.
Myasthenia Gravis
Anticholinesterase medication - cholinesterase (enzyme that breaks down acetylcholine) inhibitors
TX of Myasthenia Gravis - Mestinon + Prostigmin - every 4-6 hrs; PO; 45-60 min before meals
Mestinon + Prostigmin - SE
Cholinesterase inhibbitors - diarrhea, cramping, increased salivation - until body adjust
Myasthenia Gravis - DX
- Blood test - acetylcholine receptor antibody ( not positive in every pt)
- Tensilon test - give drug to increase acetylcholine (short life) - within a minute - improvement in S/s
COMPLICATION - PNS - bradycardia ( Atropin )
Myasthenic crisis vs cholinergic crisis
Meds not on time ; throwing up due to illness or infection vs too much meds
Medications that should be avoided with myasthenia gravis
- Morphine
- Curare
- Quinine (antimalarial)
- Quinidine + Procainamide -Antiarrhythmic drugs
- Mycin-type antibiotics
- Drugs containing magnesium
MS - DX
- MRI - can see plaques - intefere with impulse to the muscle
- LP - SCF - immunoglobulins (IgG)
- Evoked potential studies - auditory, visual
Multiple Sclerosis - exacerbation/ acute phase tx
- Steroids - big doses - Solu-Medrol
- ACTH ( hormone from pituitary gland - adrenal cortex - increase secretion of corticosteroids )
Priority nursing diagnosis for patient with spinal cord injuries at C 5 or higher
- Ineffective Airway Clearence
- Ineffective Breathing Pattern
- Impaired Gas Exchange
Closely monitor the pt for pneumonia, PE, atelectasis - this problems decrease life expectancy of SCI patients - leading cause of death
Decadron + Solu-Medrol - use and SE
High doses steroids are given asap after spinal cord injury to reduce edema ; IV; SE: Infection, elevated serum glucose, stress ulcers ; low K.
Intervertabral disc herniation and degenerative disk disease - most common regions ?
Lumbur (5) - legs + Cervical (7) - shoulders and arms
Intervertebral disk herniation + degenerative disc disease - non-surgical management
- NSAIDs
- Medrol Dosepak - steroid
- Muscle relaxants - Robaxin + Flexeril - may help control severe muscle spasticity (UMN injuries) ; spasms
SE: severe drowsiness + sedation
Sciatic Pain
pain, weakness, numbness or tingling in the leg - herniated disk - lumbar region (5)
Microdiskectomy
Involves microscopic surgery directly through 1-inch incision ; endoscope - remove herniated disk - relieve pressure ; 24 hrs - in and out
Removal of part of laminae and facet joints to obtain access to the disk space ; when repeated laminectomies are performed or if the spine is unstable - spinal fusion is performed to stabilize affected area ; chips of bone are removed (from iliac crest) or obtained from donor bone and are grafted between vertebrae for support and to strenghten the back - metal implants (titanium pins, screws, plates or rods) may be used to ensure the fusion of the spine
Laminectomy
Laminectomy - post op - correct turning - log rolling
Every 2 hours from side to back and vice versa ; pt turns as a unit while his or her back is kept as strainght as possible
Anterior cervical diskectomy and fusion - cervical corpectomy
The priority of care is maintaining airway - swelling from surgery can narrow the trachea causing a partial obstruction
No lifting
No driving until physician permission
No strenuous activities
Walk every day
Wear brace or collar per surgeons prescription
S/s of spinal tumor - depends on location (thoracic 12 - most common)
- Pais due to pressure on the spinal cord nerve roots
- Numbness
- Tingling
- Loss of bladder/bowel function
- Foot drop
Spinal shock
trauma to cord itself - flaccid paralysis initially - 4 hrs-2 weeks - until pt comes out of this state - can’t assess how much function pt will have - all reflexes are gone - no peristalsis - Risk - paralytic ileus (NG tube) ; Foley.
Amyotropic Lateral Sclerosis - DX
- Increased CK
- Abnormal EMG - electromyogram - give shocks to see how muscle responses - fasciculations (twitching)
- Dysarthria + Dysphagia
Cushings syndrome
Dilantin - SE
Antiepileptic - Antiseizure med - Gingival hyperplasia (overgrowth of gum tissue) - Dental care !!!
Cushings triad
classic but late sign of increased ICP
- Severe hypertension
- Widened pulse pressure
- Bradycardia
ICP
keep below 20
Meningitis S/s:
- Fever
- Headache
- Nuchal rigidity ( neck stiffness)
- Increase in WBC
- Brudzinskis and Kernigs signs
SIDH - TX
- Fluid restriction - ( 800 ml/ 24 hrs)
- If Na very low ( < 125) - 3 % Saline solution - small amount , slowly - monitor closely - Risk for cerebral edema !!!
Craniotomy -
- Supratentorial - cerebrum
- Infratentorial - cerebellum
Brain Tumors - S/s - depends on location
- Changes in personality or behavior (frontal lobe)
- Headache
- N+V
- Seizures
- Visual disturbances (occipital lobe)
- Balance and coordination problems ( cerebellum) - ataxia, falls
Antiseizure meds and SE
- Dilantin, Tegretol, Klonopin, Neurontin , Depakote, Valium
SE: drowsiness, lethargy, sleepiness, sedation (until get adjusted ) Do not drive !!!; Blood dyscrasia (CBC)
PO corticosteroids
give in the morning ; with food (breackfast)
Stereotactic Radiosurgery - advantages
for deep seated brain tumors : shrink (radiation) - no incision
- noninvasive nature
- lower risk, cost, morbidity , length of hospital stay , recovery time
Autonomic Dysreflexia - T6 or higher - pathophysiology
Noxious stimulus (distended bladder or bowel) - stimulates SNS - vasoconstriction - pounding headache + severe hypertension** (Risk - Stroke) - baroreceptors of carotid sinus + aortic arch stimulate vagus nerve (PNS) - **decreased HR + nausea** - dilates skin vessels above level of injury - _flushing, diaphoresis, nasal congestion _**
Autonomic Dysreflexia - Nursing Management
- Head up
- Call for help
- Assess for + remove noxious stimulus ( catheterize, disimpact )
- Monitor BP Q 10-15 min
- CCB (IV) or Nitrates (Nitroglycerin, Procardia) - sublingual
Niphedipine (Procardia)
Nimodipine (Nimotop)
Verapamil (Calan)
Calcium Channel Blockers - tx cerebral vasospasm , hypertension
Ruptured aneurysm S/s
Severe headache , N&V - die quickly if massive hemorrhage
Aneurysm that is leaking - S/s
headache , stiff back and legs, intermittent nausea
Strokes - FAST
Complications of aneurysm
- Vasospasm - 4-10 days after initial bleed - ischemic episode - brain tissue death
tx: Prevent !!! - control BP - CCB ( Procardia, Verapamil, Nimotop) - Re-bleed - bleed that seals itself can re-bleed within 24-48 hrs or 7-10 days later
Cervical injury suspected - how to open airway
Jaw thrust - fingers behind the mandible - push forward - will bring tongue forward
Tetraplegia, also known as quadriplegia
Complete paralysis of the body from the neck down.
Paraplegia
impairment in motor or sensory function of the lower extremities
