Neuro Flashcards

1
Q

What are some general questions you might want to ask your pt as part of the neuro exam?

A
  • 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
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2
Q

What is your goal for the pre-op neuromuscular assessment?

Why is this importnat?

A
  • 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
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3
Q

How do you assess the temporomandibular joint?

A
  • 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
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4
Q

How do you assess the cervical spine?

A
  • Flexion- chin to chest
  • extension- look up
  • rotation
  • lateral bending
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5
Q

How do you assess the shoulder girdle?

A
  • 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
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6
Q

What is thoracic outlet syndrome?

why do we care about this?

A
  • 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
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7
Q

How do you assess the pts elbow?

A
  • ask pt to bend and straighten elbow
  • with arms at sides and elbows flexed instruct pt to turn palms up (supination) and down (pronation)
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8
Q

How do you assess the hip?

A
  • 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!
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9
Q

How can you assess the nervous system?

A
  • mental status
  • speech
  • cranial nerves
  • gait
  • motor function
  • sensory function
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10
Q

How do you assess cranial nerves

I

II

III

A
  • 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
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11
Q

How do you assess cranial nerves

IV

V

VI

A
  • 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
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12
Q

How do you assess Cranial nerve VII?

A
  • CN VII- Facial
    • have pt raise both eyebrows
    • frown
    • close eyes tightly so you cant open them
    • show teeth
    • smile
    • puff out cheeks
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13
Q

How do you assess cranial nerves

VIII

IX & X

A
  • 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
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14
Q

How do you assess Cranial nerve

XI

XII

A
  • 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
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15
Q

How is the assessment of muscle strength graded?

A
  • 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
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16
Q

Weakness or change in elbow flexion would indicate an injury at ___, ___

elbow extension ___, ____, ____

A

flexion: C5, C6
extension: C6, C7, C8

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17
Q

A changed or weaked grip strength would indicate injury at ____, ____, _____

A
  • C7, C8, T1
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18
Q

A change or weakness in finger abduction would indicate an injury where?

A

C8, T1, ulnar nerve

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19
Q

A weakness or change in ability to oppose the thumb would indicate an injury where?

A

C8, T1, median nerve

20
Q

A change in strength or inability to flex or adduct the hip would indicate an injury where?

A

L2, L3, L4

21
Q

A change in strength or inability to abduct hip would indicate an injurey where?

A

L4, L5, S1

22
Q

A change in strenght or inability to extend hip would indicate an injury where?

A

S1

23
Q

Problems extending knee,

injury where?

A

L2, L3, L4

24
Q

problems flexing knee,

injury where?

A

L4, L5, S1, S2

25
Q

Problems with dorsiflexion,

injury where?

plantar flexion?

A

L4, L5

plantar flexion S1

26
Q

What is the glascow coma scale?

A
  • 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
27
Q

What are some noteworthy medications your pt with neuromuscular disease might be on?

A

steroids

MAOIs

methotrexate

28
Q

Steroids

whats the problem steroids can cause?

what are the guidelines for who gets treated?

what are the two regimens?

A
  • 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
29
Q

MAOIs

what is the problem?

what should be avoided?

A
  • 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
30
Q

What are the MAOIs?

(7)

A
  • Iproniazid
  • phenelzine
  • isocarboxazid, meclobemide
  • befloxatone
  • brofaromine
  • selegiline
31
Q

Methotrexate

who takes it? (neuromuscular pts)

what does it cause?

What should you check?

A
  • 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
32
Q

What are the main questions you should ask a pt with MS?

A
  • Steroids in the last year?
  • any recent illness or infection?
  • What medications?
  • What are remission and exacerbation intervals?
  • severity and nature of symptoms
    • triggers
33
Q

What should you document for a pt with MS?

what should you council the pt regarding?

A
  • 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
34
Q

What should you document for a Guillian Barre pt?

A
  • 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
35
Q

What do you want to ask of a pt with parkinson’s disease?

A
  • 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
36
Q

What do you need to do with a Parkinson’s deep brain stimulator?

A

deactivate it before electrocautery

37
Q

What do you need to assess for a pt with a disk herniation?

What is a concern if the surgery is a redo?

A
  • 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
38
Q

What do you need to assess for a pt with ankylosing spondylitis?

What labs/tests would you want?

what should you have pt discontinue?

A
  • 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
39
Q

What do you need to know about a pt with a spinal cord injury?

A
  • 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
40
Q

What is important to know if your pt has a history of TIA or CVA?

A
  • 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
41
Q

How long should you wait after a stroke to take a person for surgery?

A

the longer the better. Try to avoid within first 9 months

42
Q

What do you need to know about a pt with CVA, head injury, or intracranial tumor?

A
  • 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
43
Q

What do you want to know about somebody’s sz disorder?

A
  • 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
44
Q

SLE basically affects every system, so you will want a very thorough workup done. What will you definitely ask your pt?

A

Exercise tolerance!

Echo, cardiac consult

Pericarditis? conduction abnormalities? CHF etc…

45
Q

What medications do you want to know the dose, frequency, and timing of last dose for a pt with SLE?

A
  • Coagulation
    • ibuprofen
    • indomethacin
    • ASA
    • cox-2 inhibitors
    • DVT preventative
  • Immuno suppressive therapy
  • steroids
  • optimized by PCP or rheumatologist?
46
Q

Dyspnea in a pt with RA is often a sign of what?

A
  • 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