Neuro Flashcards
What are some general questions you might want to ask your pt as part of the neuro exam?
- Have you ever had a sz, stroke, or paralysis?
- have you ever been diagnosed as having a tremor or parkinsons dx?
- have you ever had numbness, tingling, or “pins-and-needles” in your arm or leg that has lasted more than 2 hours?
- Have you ever had nerve injury, MS, or any other nervous system disease?
- Have you had migraine HAs?
- Have you been working at your usual jobs or activities?
- there are more…..also ask more clarifying questions if they answer yes
What is your goal for the pre-op neuromuscular assessment?
Why is this importnat?
- Goal to determine range of motion, any abnormalities or joint problems
- This is important b/c we will take away the normal protective pain reflexes with anesthesia
- dont want to injur them further
How do you assess the temporomandibular joint?
- Place tips of index finger just in front of the tragus of ear, ask pt to open mouth
- fingertips should drop into joint spaces as mouth opens
- check for smooth range of motion, swelling/tenderness
- snapping and clicking is normal
- ask pt to open and close mouth, protrude and retract jaw and side to side
How do you assess the cervical spine?
- Flexion- chin to chest
- extension- look up
- rotation
- lateral bending
How do you assess the shoulder girdle?
- 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 side
- place both hands behind the small of back
What is thoracic outlet syndrome?
why do we care about this?
- compression of brachial plexus and subclavian vessels near the first rib
- be certain pt can work or sleep with arms elevated over their head before putting arms beside head
- we care because arms are better above head for prone positioning
How do you assess the pts elbow?
- ask pt to bend and straighten elbow
- with arms at sides and elbows flexed instruct pt to turn palms up (supination) and down (pronation)
How do you assess the hip?
- focus on ROM that will affect 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, this is their limit!
How can you assess the nervous system?
- mental status
- speech
- cranial nerves
- gait
- motor function
- sensory function
How do you assess cranial nerves
I
II
III
- CN I: (olfactory) have them smell something; vanilla or mint
- CN II: (optic)
- sight confrontation test- stand in front of pt, both covering mirrored eye, bring finger in from the periphery, both should see it at same time
- pupillary reaction to light
- CN III: (oculomotor) pupillary reaction to light, look for extraoccular movements
How do you assess cranial nerves
IV
V
VI
- CN IV: (trochlear) look for extraoccular movements
- CN V: (trigeminal)
- ask pt to clench teeth as you paplate temporal muscles
- check sensation (see pic)
- corneal reflex with cotton ball
- CN VI: (abducens) look for extraoccular movements
How do you assess Cranial nerve VII?
- CN VII- Facial
- have pt raise both eyebrows
- frown
- close eyes tightly so you cant open them
- show teeth
- smile
- puff out cheeks
How do you assess cranial nerves
VIII
IX & X
- CN VIII ( acoustic)- this is done by audiology
- CN IX & X ( glossopharyngeal and vagus)
- listen for voice hoarseness
- gag reflex
- say AHHH, palate should rise symmetrically
How do you assess Cranial nerve
XI
XII
- CN XI: (spinal accessory)
- have pt turn their head side to side against your hand
- ask pt to shrug both shoulders up against your hand
- CN XII: (hypoglossal)- ask them to stick out tongue
How is the assessment of muscle strength graded?
- test flexion and extension and compare symmetry
- Grade 0-5 scale
- 0- no muscle contraction detected
- 1- barely detectable
- 2- active movement with gravity eliminated
- 3- active movement against gravity
- 4- active movement against gravity with some resistance
- 5- active movement against gravity with full resistance
Weakness or change in elbow flexion would indicate an injury at ___, ___
elbow extension ___, ____, ____
flexion: C5, C6
extension: C6, C7, C8
A changed or weaked grip strength would indicate injury at ____, ____, _____
- C7, C8, T1
A change or weakness in finger abduction would indicate an injury where?
C8, T1, ulnar nerve
A weakness or change in ability to oppose the thumb would indicate an injury where?
C8, T1, median nerve
A change in strength or inability to flex or adduct the hip would indicate an injury where?
L2, L3, L4
A change in strength or inability to abduct hip would indicate an injurey where?
L4, L5, S1
A change in strenght or inability to extend hip would indicate an injury where?
S1
Problems extending knee,
injury where?
L2, L3, L4
problems flexing knee,
injury where?
L4, L5, S1, S2
Problems with dorsiflexion,
injury where?
plantar flexion?
L4, L5
plantar flexion S1
What is the glascow coma scale?
- Eyes opening
- never- 1
- spontaneous- 4
- best verbal response
- none- 1
- oriented- 5
- best motor response
- none- 1
- obeys commands- 6
- **less than 8, intubate
What are some noteworthy medications your pt with neuromuscular disease might be on?
steroids
MAOIs
methotrexate
Steroids
whats the problem steroids can cause?
what are the guidelines for who gets treated?
what are the two regimens?
- steroids are problematic b/c pt will not respond appropriately to the stress of surgery
- Any pt who has received corticosteroid therapy for at least one month in the past 6-12 months will need supplementation
- regimens
- 100 mg hydrocortisone pre-op, intr-op, and post-op
- 25 mg hydrocortisone pre-op, 100 mg IV gtt over 12-24 hrs
MAOIs
what is the problem?
what should be avoided?
- Prevent the breakdown of monoamines, causing there to be increased amt available in presynaptic nerve terminal
- Life threatening interactions when given:
- ephedrine
- meperidine
- foods with tyramine
What are the MAOIs?
(7)
- Iproniazid
- phenelzine
- isocarboxazid, meclobemide
- befloxatone
- brofaromine
- selegiline
Methotrexate
who takes it? (neuromuscular pts)
what does it cause?
What should you check?
- Used in MS, ankylosing spondylitis and RA
- immuno-suppression, anemia, thrombocytopenia, pulmonary toxicity, renal and hepatic toxicity
- check:
- cbc
- chemistry
- PFTs and LFTs if history warrants
What are the main questions you should ask a pt with MS?
- Steroids in the last year?
- any recent illness or infection?
- What medications?
- What are remission and exacerbation intervals?
- severity and nature of symptoms
- triggers
What should you document for a pt with MS?
what should you council the pt regarding?
- paralysis (muscle strength)
- sensory disturbances (assess along dermatomes)
- autonomic disturbances (resting HR and orthostatic hypotension)
- visual impairment (cranial nerve check)
- seizures
- emotional disturbances
- **Council pt regarding increased relapse with surgery
What should you document for a Guillian Barre pt?
- time course for the disease
- severity and current state of symptoms
- ANS dysfunction
- review ICU flowshoeats, talk to nurse
- ECG, recent arrhythmias
- vasoactive med requirements
What do you want to ask of a pt with parkinson’s disease?
- Age of dx,
- recent exacerbations or hospitalizations?
- Curret and past symptoms
- Ex. Oculogyric crisis? How long did it last? What helped?
- ANS symptoms
- History of Pergolide therapy?
- temp regulation issues?
- dysphagia or dyspnea?
- pulmonary infection
What do you need to do with a Parkinson’s deep brain stimulator?
deactivate it before electrocautery
What do you need to assess for a pt with a disk herniation?
What is a concern if the surgery is a redo?
- natural ROM for positioning and laryngoscopy
- baseline motor strength and sensation
- medication regimen
- what helps pain? what is ineffective
- consider blood loss
- high blood loss if surgery is a redo
- CBC
- type and cross
What do you need to assess for a pt with ankylosing spondylitis?
What labs/tests would you want?
what should you have pt discontinue?
- severity of kyphosis, ROM
- evaluate for co-existing vasculitis, aortitis, aortic insufficiency, pulmonary fibrosis
- SpO2, ECG, echo, CXR, PFTs
- CBC, BUN, Cr
- discontinue NSAIDS at least 2 days pre-op
What do you need to know about a pt with a spinal cord injury?
- level of lesion
- acute vs chronic
- Acute
- fluid and blood status (CBC, Type and cross, Chem)
- ECG, CXR
- vasopressor requirement?
- ventilatory support? settings?
- associated injuries?
- Chronic
- History of AD?
- Old OR/ICU records
- ventilatory reserve, level of lesion
- skin integrity
- positioning
What is important to know if your pt has a history of TIA or CVA?
- Ensure that they have been optimized
- Was PFO corrected?
- if they have A-fib, have they been on anticoagulation therapy for 1-3 months
- do you note a carotid bruit on exam?
- does not increase risk if asymptomatic
- Any TIA symptoms
How long should you wait after a stroke to take a person for surgery?
the longer the better. Try to avoid within first 9 months
What do you need to know about a pt with CVA, head injury, or intracranial tumor?
- mechanism of injury or illnes
- location, size and time course from lesion
- CT or MRI report (secondary edema?)
- ICP status- current symptoms
- evaluate cardiovascular status
- will they handle mannitol?
- consider cranial nerve assessment
- muscle strength and sensation assessment
- Review current meds and treatments
- review current ventilatory status
- note baseline vital signs and set BP parameters
- continue current medications
What do you want to know about somebody’s sz disorder?
- Type of sz activity, typical length, frequency, severity, recovery period
- precipitating/causative factors
- Hz of status; what treatments were effective?
- pharmacologic therapy
- CBC, plt, electrolyte panel
- cancel elective surgery until sz d/o optimized by neurologist
SLE basically affects every system, so you will want a very thorough workup done. What will you definitely ask your pt?
Exercise tolerance!
Echo, cardiac consult
Pericarditis? conduction abnormalities? CHF etc…
What medications do you want to know the dose, frequency, and timing of last dose for a pt with SLE?
- Coagulation
- ibuprofen
- indomethacin
- ASA
- cox-2 inhibitors
- DVT preventative
- Immuno suppressive therapy
- steroids
- optimized by PCP or rheumatologist?
Dyspnea in a pt with RA is often a sign of what?
- cardiac ischemia
- Get PFTS and ABG if you suspect lung involvement
- ECHO, ECG if cardiac involvement suspected
- Consider the effect of medications
- ASA
- nsaids
- methotrexate
- immunosuppressive drugs
- steroids
- balance preference to continue drugs with anti-coagulation and immunosuppressive characteristics
