PNS & CVA Exam Flashcards
What are the two types of PNS disorders
Neuromuscular
Cranial nerve disorders
Define Neuromuscular disorder
are chronic and degenerative.
They disrupt the transmission of impulses b/w neurons and the muscles they stimulate.
Define Multiple Sclerosis or MS
MS Involves the degeneration of myelin sheath
Myelin covers the axons and is responsible for the smooth transmission of nerve impulses.
It can be damaged due to inflammation, detachment, or if it becomes swollen.
Onset 20s to 40s
etiology of MS
Unknown
Possible autoimmune response
Possible viral infection
Heredity
What are the two types of MS
Relapsing remitting (most common): worsening signs and symptoms followed with improvement Progressive MS: gets worse without improvement
What are problems associated with MS
Weakness/paralysis of limbs Double /blurred vision Slurred speech Spasticity of muscles Numbness Tinnitus and vertigo Dysphagia Spastic or flaccid bladder Mood swings
What can trigger onset of symptoms in MS
extreme heat extreme cold fatigue infection emotional stress
S/S of MS
tinnitus decreased hearing urinary retention spastic bladder constipation nystagmus blurred vision dysarthia dysphagia weakness or paralysis ataxia vertigo
Dx of MS
H&P: symptoms that the patient reports
MRI: will detect sclerotic plaques and will rule out other disease processes.
Lab tests: aides in diagnosing and ruling out other diseases.
Therapeutic interventions for MS
Steroids: Decrease inflammation of the neurons. They are given oral or IV.
Immunosuppressant’s: given to depress the immune system
Anticonvulsants: Relieve neuro pain
Muscle relaxants: Control muscle spasms
PT/OT: Help adapt to home environment
There is no cure: Treat symptomatically
Rehab after an acute episode includes PT, Speech therapy, and OT.
Patient teaching includes: to teach the patient to avoid factors that can exacerbate symptoms.
What is needed for muscle contraction
Acetylcholine
What is Myasthenia Gravis
When there is none or the receptors for Acetylcholine are destroyed. The contraction doesn’t take place
The muscle weakness occurs during activity and improves with rest.
It effects the facial muscles, neck, and limb movement.
S/S of Myasthenia Gravis
Progressive muscle weakness Fatigue with activity Ptosis (droopy eyelids) Difficulty chewing and swallowing Difficulty breathing An early sign can be double vision or slurred speech
Complications of Myasthenia Gravis or MG
Aspiration
Respiratory infection and failure
What is Mysathenic crisis
Sudden onset of symptoms due to not enough medication or triggered by infection
What is a Cholinergic crisis
due to overmedication
What is anti cholinesterase
drugs help improve nerve-muscle communications and increase your muscle strength
Medications given of MG
anticholinesterase
corticosteroids
What is a Tensilon test
Anticholinergic med is given and there is temporary improvement of droopy eyelids. It is an injection of tensilon and muscle strength improves for 1-3 minutes.
pt education for MG
Methods to conserve energy Avoidance of infection Signs and symptoms of crisis Support group Encourage timing of meds so peak of drug will be used when most needed
therapeutic interventions for MG
Can be controlled with meds: they improve neuromuscular transmission and increase muscle strength. They also slow down the time of acetylcholine breakdown.
Immunosuppressive drugs: decrease the production of antibodies.
Surgery: to remove the Thymus. This will work on the immune system so it doesn’t work against the body.
pathophysiology of Amyotrophic Lateral Sclerosis aka Lou Gehrig’s Disease
Motor neurons degenerate: they stop sending messages and nerve impulse transmission are then blocked.
This results in muscle weakness and atrophy
As it progresses, it effects the muscles that control breathing and swallowing.
Etiology of ALS aka Lou Gehrig’s Disease
Unknown
Possible genetic predisposition
Possible Auto-immune disorder
REMEMBER: this doesn’t effect the brain!! Only motor neurons!
Description of ALS or Lou Gehrig’s Disease
Amyotrophic lateral sclerosis causes both the upper and the lower motor neurons that control voluntary movement to die off.
This leads to weakness, muscle death and then paralysis.
The disease begins with the lesser needed muscles, moves to the arms and legs and eventually the muscles that control swallowing and breathing.
Patients inevitably end up on feeding tubes and ventilators.
S/S of ALS
Progressive muscle weakness (gradual): The muscles weaken, and waste away.
Decreased coordination
May effect 1 leg = stumbling
or hands = can’t button shirt
Muscle spasms occur
Difficulty chewing and swallowing
Speech difficulty
Pulmonary compromise: this is when the muscles of the diaphragm are effected. They eventually end up on a vent.
Eventual loss of voluntary movement and can not move
Death in 3–5 years due to complications.
Dx of ALS
assessment of symptoms
nerve biopsy
Therapeutic Interventions for ALS
Muscle relaxants: to control muscle spasticity and cramps PT/OT/Speech therapy Pain control Infection precautions (URI’s and UTI’s) Good skin care Communication support Tube feedings due to decreased nutritional status and easily chokes. Prevention of infection
Pathophysiology of Guillain-Barre Syndrome
Myelin sheath of the spinal cord and cranial nerves is destroyed d/t an inflammatory reaction which cause a slowed or blocked nerve conduction.
Immune system begins attacking the nerves that cary signals to your brain
Commonly follows a respiratory infection
What are the 2 main categories of Guillain-Barre Syndrome
Ascending: characterized by progressive weakness beginning in the legs and works it’s way up the body
Descending (less common) affects the cranial nerves of the brain stem first, making difficulty in swallowing and speaking and progresses downward to the legs.
S/S of Guillan-Barre Syndrome
Starts with the onset of symptoms and lasts until the progression of symptoms stop.
Abrupt onset weakness and paralysis
May affect respiration
Pain ranges from numbness to intense pain
Progression of symptoms stops
Some recover completely and others have debilitations
Complications of Guillan-Barre Sndryome
Respiratory failure
Infection
Depression
Therapeutic Interventions for Guillan-Barre Syndrome
The goal of therapy is to support body systems until the patient recovers. Monitor respiratory status Manage pain Tube feedings if indicated Communication board
Dx of Guillan-Barre Syndrome
LP
EMG
Nerve conduction velocity
Pathophysiology of Trigeminal Neuralgia (aka Tic douloureux)
Involves the fifth cranial nerve (trigeminal)
The 5th cranial nerve has three branches so it effects different parts of the face.
Effected are the forehead, nose, cheek and jaw
May be from irritation or chronic compression of the cranial nerve.
S/S of Trigeminal Neuralgia
Intense pain on one side of face
The periods of pain last from seconds to minutes and can last several days.
Triggered by items such as touching the face or talking.
Sleep provides a period of relief
As time progresses, the episodes become more frequent.
Treatment for Trigeminal Neuralgia
Anticonvulsants: Reduce transmission of nerve impulses
Nerve blocks: Provides a longer period of relief than meds.
Surgery: To remove the nerve or pad it
Pathophysiology of Bell’s Palsy
Cranial nerve VII is effected
The 7th cranial nerve controls most facial muscles, ears, and salivation/tearing
Patient looses motor control on one side of face.
Contracture may develop
Palsy = paralysis
Etiology of Bell’s Palsy
unknown
possible viral infection of nerve
can also occur in 3rd trimester of pregnancy
S/S of Bell’s Palsy
One sided facial nerve quits working forehead not wrinkled Eyeball rolls up eyelid does not close Speech difficulties Weakness: Mouth droops Can’t close eyes
Treatment of Bell’s Pasly
Prednisone: top decrease edema and swelling
Gentle massage: keeps the face flexible for when it heals.
Facial sling: supports the muscles
Eye patch and drops to decrease drying of eyes
Prevention of complications is the goal because 80% of pts recover within weeks to months.
Rarely does it reoccur.
When vessels of the brain are unable to supply blood and oxygen to the brain cells, brain tissue dies causing a ___, ____, or ___ ____
CVA
TIA
Subarachnoid hemorrhage
Define CVA
infarction (death) of brain tissue caused by the disruption of blood flow to the brain.
It is characterized by neurological deficits specific to the area of the brain involved!
The patient does not return to baseline functional level.
If patients receive treatment within __ hours of symptom onset, they may be able to received medication that has the potential to resolve their deficits. So time is important!!
3
Pathophysiology of Brain attack (CVA, Stroke)
Inadequate blood flow to brain
Infarction and death of brain tissue results
Permanent damage if not reversed
two types of ischemic strokes
**Thrombotic: when the arteries are narrowed due to atherosclerotic plaque.
**Embolic: If emboli break away and travel/lodge in the vessels.
What is a hemorrhagic stroke
Bleeding into the brain caused by rupture of a cerebral blood vessel.
This causes the brain tissue beyond the vessel not to receive oxygen and nutrients and cause necrosis.
These types of strokes are caused by uncontrolled HTN, aneurysm’s, and use of illegal drugs.
modifiable risk factors for stroke
High blood pressure Smoking Diabetes Atherosclerosis Atrial Fib TIA’s Sickle cell anemia High cholesterol Obesity Excessive ETOH intake Use of illegal drugs
non-modifiable risk factors for a stroke
Older age
Sex
Heredity
Prior stroke or Heart attack
S/S of a stroke
*depend on vessel involved* Change in LOC Fever Headache Vomiting Seizures Numbness Weakness Paralysis Language difficulty Vision changes Impaired coordination Neurological deterioration Respiratory compromise
Long-term effects from a CVA
Motor function
Hemiplegia: ½ of opposite side of body is flaccid
Dysphagia: unable to swallow
Aphasia
Expressive: understands what is said, unable to communicate
Receptive: does not understand what is said
Global: combination of the two
Emotional lability: Unstable mood swings
Impaired judgment: particularly those with right sided lesions
Unilateral neglect: Does not acknowledge the other ½ of the body
Dx of a stroke
Cincinnati Pre-hospital Stroke Scale
CPSS
If a patient who has one of the 3 possible findings, they have a 72% probability of having an ischemic stroke and needs to be sent to the ER ASAP!
- Have the patient smile. Look for subtle signs of facial droop or uneven symmetry of the face
- Ask the patient to hold the arms out straight in front while closing the eyes. Observe the patient’s arms closely for any signs of drifting downward.
- Ask the patient to repeat a phrase, such as “It is a bright and sunny day in East Grand Forks”. Did the patient understand? Did he repeat the phrase exactly? Did he exhibit any slurred speech or difficulty saying the words?
Dx tests for stroke
CT scan and/or MRI:
ECG: to check for atrial fibrillation or other cardiac history
Arteriogram
Carotid Doppler: can check for stenosis of the carotid arteries
Therapeutic interventions for a stoke
Thrombolytic Therapy If the stroke is ischemic, thrombolytic therapy must be given within 3 hours of the onset of symptoms to be effective An example is tPA which can dissolve a clot and potentially reverse stroke symptoms TIME IS BRAIN! Airway Management Keep saturations above 92% Control of Hypertension Seizure Prevention
Post-Emergent interventions for a stoke
Maintain Patent Airway: high risk for aspiration
Treat Cause of Stroke
Once the cause is determined, the physician will treat accordingly
Physical, Occupational, Speech Therapy
Antiplatelet Agent: within 24 hours to lessen the chances of thrombus formation
(Plavix, Aggrenox, or aspirin)
Anticoagulant Agent & Antidysrhythmic Agent
If atrial fibrillation was the cause of the TIA/CVA
This is also given to prevent potential DVT’s that can result post CVA
Possible surgical treatments for a stroke
Craniotomy
Endarterectomy
Balloon angioplasty
______ Aneurysm
Weakness in artery wall, if it ruptures it leads to a:
______ hemorrhage
Cerebral
Subarachnoid
subarachnoid hemorrhage is bleeding from:
Aneurysm
Head trauma
Any activity that requires strain
describe a subarachnoid hemorrhage
bleeding into the space between the inner layer and middle layer of the tissue covering the brain (meninges).
Usually, rupture of an artery causes a sudden, severe headache, often followed by a brief loss of consciousness.
S/S of a subarachnoid hemorrhage
pain above and behind the eye Numbness weakness paralysis on one side of the face dilated pupils vision changes
Dx of a subarachnoid hemorrhage
CT scan: done to identify the presence and location of a hemorrhage.
Cerebral angiogram: more precise than the CT scan
MRI
therapeutic interventions for subarachnoid hemorrhage
Treatment consists of correcting the cause of the hemorrhage if possible.
Craniotomy
Clamped with a clip if berry aneurysm is identified
This provides stability to the aneurysm walls and lessens the chance of rupture.
Thrombotic
Caused by a clot
Aphasia
Inability to speak or understand language
Dysphagia
Difficulty swallowing
Hemianopsia
Vision lost in half of visual field
Flaccid
Without muscle tone
Ataxia
Imbalanced, staggering gait
Diplopia
Double vision
Hemiplegia
Paralyzed on one side of the body
Penumbra
Healthy tissue surrounding an infarct
Ischemic
Deficient blood flow to organ or tissue
Match the drug with its action
Heparin
Anticoagulant
Match the drug with its action
clopidogrel (Plavix)
Antiplatelet
Match the drug with its action
tissue plasminogen activator (rPA)
Thrombolytic
Match the drug with its action
simvastatin (Zocor)
Cholesterol lowering agent
What is the term or acronym for a temporary impairment of cerebral circulation that causes symptoms lasting minutes to hours but results in no permanent neurologic changes?
- TIA
- CVA
- SAH
- Stroke
TIA
The others all cause permanent deficits
A post-myocardial infarction patient experiencing atrial fibrillation is most at risk for which type of stroke?
- Hemorrhagic stroke
- Embolic stroke
- Thrombotic stroke
- Cerebral aneurysm
Embolic stroke
In atrial fibrillation, the blood is not ejected normally and small clots may develop in the atria. If these clots are ejected into the circulation as emboli and travel to the brain, an embolic stroke occurs.
The nurse is providing care for a patient with a hemorrhagic stroke. Which of the following medication would the nurse question? (SELECT ALL)
- simvastatin (Zocor)
- clopidogrel (Plavix)
- carbamazepine (Tegretol)
- tissue plasminogen activator (tPA)
- metoprolol (Toprol)
- warfarin (Coumadin)
- clopidogrel (Plavix)
- tissue plasminogen activator (tPA)
- warfarin (Coumadin)
Muscles that are not used become wasted, or ___
atrophied
Some diseases are characterized by remission and ___
exacerbations
Nerve pain is also called ___
neuralgia
An early symptom of myasthenia graves is drooping eyelids, also called ___
ptosis
Symptoms of Guillain-Barre syndrome are caused by ____ of axons
demyelination
Myasthenia graves is sometimes treated with ___ which separates blood cells from plasma to remove antibodies
plasmapheresis
Muscle twitching, or ____, occur in amyotrophic lateral sclerosis
fasciculations
Medications for myasthenia graves that can increase acetylcholine at the neuromuscular junction are called ___ agents.
anticholinesterase
Which drug class is used to reduce symptoms of muscle weakness from myasthenia gravis?
- Anticholinesterase drugs
- Anticholinergic drugs
- Adrenergic drugs
- Beta-blocker drugs
Anticholinesterase drugs
Which of the following nursing interventions will help prevent complications in the patient with Bell’s palsy?
- Megavitamin therapy
- Elastic bandages
- Application of ice to the affected area
- Lubricating eyedrops
Lubricating eyedrops
Which data collection activity will help the nurse determine if the patient with Bell’s palsy is receiving adequate nutrition?
- Monitor meal trays
- Measure intake and output
- Check twice weekly weights
- Evaluate swallowing reflex
Check twice weekly weights
A 32 year old patient is admitted to a medical unit with a diagnosis of Guillain-Barre syndrome. The patient;s legs are weak, causing difficulty walking without assistance. Which of the following is most likely responsible for this syndrome?
- Bacterial infection
- Heredity
- High fat diet
- Autoimmune reaction
autoimmune reaction
Patients with Guillain-Barre syndrome should be closely monitored. Which of the following lab results is most important to monitor for acute complications?
- Blood urea nitrogen and creatinine
- Arterial blood gases
- Hemoglobin and hematocrit
- Serum potassium
Arterial blood gases
ABGs monitor respiratory function. Deteriorating ABGs signal respiratory failure from weakening respiratory muscles
A patient who is newly diagnosed with multiple sclerosis asks what medication are used to help control symptoms and treat the disease. Which of the following medications would the nurse include in the teaching?
- acyclovir (Zovirax)
- adrenocorticotropic hormone
- thyrotropin
- diphenhydramine (Benadryl)
adrenocorticotropic hormone (ACTH)
A 19 year old student develops trigeminal neuralgia. Which of the following actions is most likely to trigger pain?
- sleeping
- eating
- reading
- cooking
eating
A nurse in a long term care facility is collecting data from an older adult client who is being observed for a transient ischemic attack (TIA). Which of the following are manifestations of a TIA? (Select all that apply.) Unilateral numbness of the arm Stiff neck Dizziness Slurred speech Otorrhea
unilateral numbness of the arm
dizziness
slurred speech
