Neuromuscular Flashcards
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1
Q
trauma involving central nervous system affects
A
brain and spinal cord
2
Q
intracranial pressure increased by
A
bleeding and swelling
3
Q
intracranial pressure can lead to
A
vasoconstriction, ischemia possibly CVA
4
Q
CT vs MRI
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CT (high speed X ray) always used first, MRI longer process so patient must be stable
5
Q
brian injury or hypoxia/ischemia dangerous b/c
A
brain has inability to store oxygen and glucose
6
Q
brain focused assessment:
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- altered level of consciousness/LOC
- confusion
- abnormal pupils (change in response to light)
- sudden onset of neurologic deficits
- changes in VS
7
Q
VS changes
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- altered respiratory pattern
- widened pulse pressure
- bradycardia
- tachycardia
- hypothermia
- hyperthermia
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Q
altered LOC signs
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- not oriented
- does not follow commands
- needs stimuli to achieve state of alertness
9
Q
myelin definition
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fat and protein that surrounds certain nerve fibers in the brain and spinal cord
10
Q
demyelination causes
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impaired transmission of nerve impulses
11
Q
multiple sclerosis definition
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chronic disease of CNS, degeneration and loss of myelin in brain, spinal cord and cerebrum.
12
Q
progressive stage of MS
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nerve impulses completely blocked
13
Q
clinical manifestations of MS; motor
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- weakness/fatigue
- paralysis
- diplopia / double vision
- spastic muscles
- ataxia
14
Q
clinical manifestations of MS: sensory
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- numbness/tingling
- vertigo
- tinnitus
- sporadic blindness
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clinical manisfestations of MS: other
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- chronic pain
- emotional instability
- bladder dysfunction
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Q
voluntary motor system; 2 types of neurons
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upper motor neuron and lower motor neuron
17
Q
upper motor neurons: pathway and location
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descending motor pathways, located entirely within CNS
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upper motor neurons: role
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modulate activity of lower motor neurons
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lower motor neurons: location
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CNS and PNS
20
Q
lower motor neurons: begin and end points
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spinal cord to muscle
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lower motor neurons: responsibility
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all voluntary movement/muscle contraction
22
Q
upper motor neuron lesions vs lower motor neuron lesions: weakness and tone
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UMN lesions - weakness distal/below point of injury (T4 or above)
UMN lesions - spastic
LMN lesions - weakness at point of peripheral nerve root
LNM lesions - flaccid tone
23
Q
multiple sclerosis MS cure?
A
no
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Q
ataxia is
A
impaired balance or coordination
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MS and the immune system
the immune system degrades the protective protein coating of nerves
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interferons: definition
treat MS, naturally made by body to control immune system
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interferon beta medication goal for MS:
reduce exacerbations (ataxia, bladder problems, etc) and slow disease progression
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interferon beta drugs: 2 types
beta - 1a (Avonex) intramuscular injection
| beta - 1b (Betaseron) subq injection
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interferon drug side effects
flu symptoms so administer at night
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drug reduces the rate of relapse of RR in MS patients
glatiramer acetate (Copaxone)
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Myasthenia Gravis definiton
autoimmune disorder affecting the neuromuscular junction
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myasthenia gravis characteristics:
fatigue and varying degrees of weakness of voluntary muscles
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acetylcholine ACh and muscle contraction
ACh attaches to nerves at neuromuscular junction and stimulates muscle contraction
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myasthenia gravis and ACh
antibodies/immune system limit number of ACh receptor sites so voluntary muscle weakness, weaker muscle contractions
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myasthenia gravis fluctuating muscle weakness intensifies
with physical activity/exercise
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myasthenia gravis fluctuating muscle weakness improves with
rest
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myasthenia gravis diagnostic tests: 2
acetylcholine/ACh test for ACh in serum
| tensilon test - edrophonium IV given and muscle strength is assessed after IV
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myasthenia gravis clinical manifestations
occular - ptosis (drooping eyelids), diplopia (double vision)
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nursing management of MG
improve function and reduce antibodies
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myasthenia gravis thymus and diaphragm
?
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skeletal muscles control
eyes, facial expression, swallowing, breathing
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skeletal muscles strength during day
strongest in morning, weaker afternoon, etc
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myasthenia gravis first line medication
anticholinesterase inhibitors - Mestinon, inhibit breakdown of ACh so can bind at neuromuscular junction and enable muscle contraction
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myasthenia gravis second line medication
immunosuppressants - reduce production of antibody
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corticosteroids role in MG
suppress immune system / inflammation
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surgery for MG
thymectomy - all or partial removal of Thymus
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nursing management of MG
chronic disease, patient seen on outpatient basis, patient and family teaching, medication management, energy conservation, aspiration risk when eating
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MG complications
Cholinergic Crisis - overmedication problem resulting in muscle weakness, respiratory impairment and excessive pulmonary secretions which can cause respiratory failure
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MG complications
Myasthenic Crisis - undermedication or infection
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myasthenic crisis priority
ventilation assistance, dysphagia, dysarthia
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MG nursing assessment
respiratory rate, depth, oxygen saturation
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Tensilon Test Myasthenic vs Cholinergic Crisis
```
Myasthenic = Tensilon Test positive
Cholinergic = Tensilon Test negative
```
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Guillain-Barre Syndrome definition
autoimmune attack on the peripheral nerve myelin
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Guillain-Barre Syndrome results in
acute, rapid segmental demyeliation of peripheral nerves > paralysis of voluntary muscle movements
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Guillain-Barre Syndrome autoimmune attack leads to
inflammatory demyelination
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sensory neurons action
carry nerve signals from periphery to the Central Nervous System
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motor neurons action
carry nerve signals from brain and spinal cord to outer parts of body - skin, muscles, glands
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Parkinson Disease cause
injury or impairment of dopmine-producing cells of the substantia nigra in the basal ganglia region of brain
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dopamine definition
neurotransmitter essential for normal functioning of extrapyramidal system /posture, support, involuntary movement
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Parkinson TRAP
Tremor - occurs at rest
Rigidity of muscles - resistance to passive limb movement
Akinesia / Bradykinesia - lack of movement, slow to initiate movement = rising from sitting position to turning in bed
Postural disturbances - poor posture, head forward when walking = fall risk
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PD primary medication
Dopaminergics aka Levodopa
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Levodopa action
converts to dopamine in basal ganglia/mid-brain
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Dopaminergics/Levodopa problems
1. unpredictable - effective for first few years
| 2. wearing off effect - immobility is when off, effective when on
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Deep Brain Stimulation is
high frequency electrical stimulation blocks tremors, patient awake
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Parkinson nursing interventions
1. hydration b/c orthostatic hypotension
2. protein intake
3. fiber intake - low dopamine levels > constipation
4. easy to chew foods b/c skeletal muscle weakness
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Parkinson head of bed HOB
full fowler's
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Parkinson risks
1. fall
2. aspiration b/c weak skeletal muscles
3. OOB out of bed with assistance
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leading cause of neuromuscular disease
trauma involving central nervous system
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cervical spinal cord 4 aka
C4, fourth from the top of the spinal cord
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C4 injury
at C4 point on the spine, ventilation dependent
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spinal cord tracts: 2
ascending - sensory pathway
| descending - pyramidal and extrapyramidal tracts
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descending tracts notable feature
cross over medulla so L Hemisphere damage, right sided effects
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pyramidal tract controls
voluntary movement
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extrapyramidal tract controls
posture, involuntary/automatic movement
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lesion aka
injury
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unm lesions
spastic
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without lower motor neurons muscles will not contract so tone will be
flaccid
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hyperextension - mechanism of injury
head back, whiplash
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hyperflexion - mechanism of injury
head down, chin into chest
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compression - mechanisim of injury
smashed together, compacted, usually spine, jump into pool
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penetrating - mechanism of injury
knife wound, gun shot
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steroid therapy med
methylprednisolone
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why treat spinal cord injuries with steroids?
reduce inflammation and swelling
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2 types of shock
1. neurogenic shock
| 2. spinal shock
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neurogenic shock is
acute high level spinal injury above T6, affects nervous system, sympathetic nervous sys doesn't work, no epi or norepi
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neurogenic shock location
upper part of spine T6 and above
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spinal shock is
loss of spinal reflex, no communication between upper motor neurons and lower motor neurons, injury anywhere on spine
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neurogenic shock VS
low BP, low HR b/c no sympathetic nervous response
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myelin regenerate? nerve?
myelin can regenerate, nerve can not
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RR aka
relapsing and recovery/remitting, disability increases over time, does not get better
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CT scan will show what for MS?
white lesions, demyelination, myelin is stripped away from nerve, myelin is white colored so lesion is the remaining white myelin surrounding the raw nerve which looks dark colored
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MS pain usually due to
spasticity
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Parkinson caused by
low dopamine
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dopamine deficiency manifestations
poor gait, poor posture
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PD confirmed when
2 out of 4 TRAP conditions
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paradoxical intoxication
symptoms get worse despite med administration
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Parkinson's unpredictability
good days, bad days, some days meds work
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carbidopa/levadopa work by
replacing dopamine by crossing blood brain barrier
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dopamine - ACh relationship
inverse, low dopamine/PD means high level ACh
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treat high level ACh with
anticholinergics/benztropine
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myasthenia gravis and thymus gland
hyperplasia of thymus gland (large thymus)
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thymus and myasthenia
thymus produces antibodies that block ACh receptor sites so muscles can't contract
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thymus diagnostic test
CT will show if enlarged
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Tensilon test positive result
admin Tensilon and muscle movement improve, dog can walk naturally again
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myasthenia gravis and diaphragm
muscles of diaphragm affected, chewing, swallowing, breathing (MGD, miller genuine draft)
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myasthenia gravis assess focus
respiratory, vital capacity (how deep can breathe), diaphragm which is a muscle
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anticholinesterase inhibitors
block enzyme that blocks ACh from binding
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anticholinergics vs anticholinesterase
anticholinergics block acetylcholine
| anticholinesterase blocks enzyme that block ACh from binding
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myasthenia treatment
give anticholinesterase = pyridostigmine
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cholinergic crisis - MG
increased pulmonary secretions, overmedication of anticholinesterase which stops enzyme from blocking acetylcholine from binding, so ACh is binding but too much so muscles stimulated to point where the stop working
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ACh/acetylcholine action
neurotransmitter that sends signals for voluntary muscle contraction
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MS, PD, MG, ALS
```
MS = myelin damage
PD = low dopamine
MG = decreased ACh receptor sites
GB = myelinated neurons paralyzed
ALS = motor neuron degeneration in brain and spinal cord
```
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C4 injury and diaphragm
C4 injury results in loss of diaphragm function so ventilator needed for breathing
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Guillain-Barre primary risk
neuromuscular respiratory failure b/c can't use diaphragm to breathe
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Guillain-Barre device to prevent respiratory failure
use incentive spirometer
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GB key symptom
symmetric weakness or paralysis of extremities (lower usually first), ascending paralysis
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GB diagnostic tests: 2
1. Lumbar puncture - CSF (cere) will show elevated protein and normal WBC count
2. EMG (electromyography) assess health of muscles and nerves that control them (motor neurons)
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GB nursing interventions goal
enhance physical mobility and prevent complications of immobility (DVT)
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Guillain-Barre typically begins with
viral infection
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Guillain-Barre stages
muscle weakness, diminished reflexes of lower extremities > hyporeflexia > tetraplegia/paralysis of all four extremities
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process that filters blood and removes antibodies from plasma portion of whole blood
plasmapheresis
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negative inspiratory force
handheld or electronic device can be attached to endotracheal tube, exhale and inhale
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ALS definition
degenerative disease loss of both upper and lower motor neurons in brain and spinal cord
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ALS impact of motor neuron death
muscle fibers served by the motor neurons atrophy
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ALS chief symptoms
fatigue and limb weakness
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ALS nerve signal impact
chemical and electrical messages exist in brain but dead motor neurons can't transport signals to muscles
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ALS diagnosis
signs and symptoms
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ALS risks
dehydration, malnutrition, pneumonia
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ALS and cognition
cognition remains intact
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ALS most common cause of death
infection/ pneumonia
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proprioception is
awareness of the position and movement of the body
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neurogenic bladder definition
urinary incontinence due to lesion in the nervous system
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neurogenic bladder: 2 types
1. reflex/spastic
| 2. flaccid
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neurogenic bladder: reflex/spastic cause
upper motor neuron lesion prevents impulses from travelling from spinal cord to voiding reflex arc/cortex
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neurogenic bladder: reflex/spastic voiding
done by reflex, no control by patient, incomplete emptying
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neurogenic bladder: flaccid cause
lower motor neuron lesion
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neurogenic bladder: flaccid effect
bladder continues to fill but no strong contraction
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neurogenic bladder: interventions
monitor I/O,
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neurogenic bladder: meds
spastic - anticholinergics - slow muscle movement
| flaccid - cholinergic to stimulate muscles of bladder
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autonomic dysreflexia definition
upper spinal cord injury, can lead to severe hypertension, nerve signal inaccurate, ex: BP rises and brain says vasoconstricton making BP higher
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autonomic dysreflexia interventions
1. sit up, HOB highest point
| 2. remove stimulus for spinal cord injury
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bowel management: 2 types
1. reflex (UMN) incontinence w/o warning
| 2. flaccid (LMN) infrequent small stools
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bowel program definition
establishes a regular time to stimulate the bowels to cause a bowel movement
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upper motor neurons and the bowels
UMN usually T12 and above, spastic, muscle spasms, colon is tight
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digital stimulation goal
stimulate reflex to defecate
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MSGB memory aid
jack coraggio is a Green Bay fan; multiple sclerosis (CNS) and Guillain-Barre (PNS) both demyelination of neurons
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injury tone: UMN and LMN
Upper Motor Neuron injury will be spastic
| Lower Motor Neuron injury will be flaccid
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flaccid muscle tone is
no muscle tone, can't contract
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spastic muscle tone is
too much muscle tone
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MS-GB recovery
jack coraggio likes Green Bay
Multiple Sclerosis chronic
Guillain-Barre can recover
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Guillain-Barre symmetrical symptoms?
yes, facial weakness, bilateral pain (charlie horse), abesent reflexes (areflexia)
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Guillain-Barre treatment: 2
plasmaphersis and Immunoglobin therapy - high does IMG to stop immune sys attacking itself
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ALS and diagnostics
muscle biopsy to determine muscle quality and atrophy
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spinal shock symptoms
all spinal reflexes below injury shut down. flaccid paralysis. 7-10 days duration
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neurogenic bladder injury location
below sacral area (bladder is lower than sacrum)
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bladder if not functional then becomes
flaccid, bladder is a muscle, paralysis or no use then flaccid
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neurogenic bladder - flaccid symptom
brain can't transmit message to bladder that it is full so overfill, urge incontinence, urine dribbles out
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flaccid bladder management
push or massage bladder to manually stimulate it
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PVR and bladder management
PVR = post void residual
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spastic bladder medications
anticholinergic to stop spasms
| skeletal muscle relaxants = propantheline
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flaccid bladder medication
cholinergics/acetylcholine/ACh to produce muscle contractions = bethanechol
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autonomic dysreflexia definition
severe vasoconstriction below injury, HTN, low HR
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autonomic dysreflexia med
nitro paste for vasodilation, admin above injury
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spinal cord injury and sensation
no sensation below injury, can't tell when to urinate, defecate
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flaccid muscles and bowel
no peristalsis > constipation
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paralytic ileus is
blockage of intestine due to paralysis
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PNS disorder affect LOC?
no
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PNS neuromuscular diseases
Guillaime-Barre and Myasthenia Gravis
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GB and MG peripheral nervous sys treatment
plasmapheresis
170
MS a respiratory problem?
no
171
infections: 2 types
respiratory and urinary
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spinal cord injury and body temp
unable to regulate it, no sweating or chills
173
Parkinson's test
passive ROM/cobwheel
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prevention of autonomic dysreflex
monitor bowels, check urinary drainage
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medic alert bracelet will not
prevent anything
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Guillaime-Barre assess for
deep tendon reflex b/c ascending paralysis, lose reflexes
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CSF should be
clear, check for infection
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impaired physical mobility due to paralysis turn patient
every 2 hours even when sleeping
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myasthenia gravis teach
abdominal thrust/Heimlich b/c choking risk
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skeletal muscles, type of muscle?
voluntary muscles
181
motor neuron disorders and skeletal muscles
motor neurons affect skeletal muscle cells
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pyramidal system
system of voluntary movement, medulla located in area called the pyramids > pyramidal system
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normal motor function steps
1. signals from brain to brain stem/medulla or spinal cord by upper motor neurons
2. brain stem/mid brain or spinal cord to skeletal muscles by lower motor neurons
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upper motor neuron lesions signs
1. no muscle atrophy
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lower motor neuron lesions signs
1. muscle atrophy b/c neurons that control skeletal muscle movement not getting there
2. flaccid paralysis, muscles don't move so sag
3. absent deep tendon reflex (patella, hit knee with hammer)
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spinal cord injury can lead to 2 types of shock:
neurogenic shock and spinal shock
187
neurogenic shock symptoms
no sympathetic nervous sys activity > no epi, no norepi > bradycardia and no vasoconstriction so hypotension
188
neurogenic shock interventions
fluids b/c low BP/hypotension
| monitor breathing
189
spinal shock symptoms
ex: compression > inflammation and bleeding > treat with methylprednisone > but blood so blood vessels constrict to stop bleeding > tissue hypoxia / ischemia
190
MS and Guillaime-Barre autoimmune / demyelination process
1. infection-fighting white blood cells and inflame the nerves
2. inflammation strips away myelin sheath from nerves
191
increase in BP, decrease in HR after spinal cord injury is symptom of
autonomic dysreflexia, risk hypertensive stroke
192
autonomic dysreflexia causes
foley catheter, constipation
193
PNS diseases GB and Myasthenia Gravis LOC?cerebral function?
no effect b/c PNS not CNS
194
GB and assessment
deep tendon / knee reflexes
195
GB vs MS
Guillaine-Barre full recovery, MS chronic
196
MG teach
abdominal thrust b/c choke risk
