Neuro /musculoskeletal

1. Neuro/musculoskeletal By: Diana Blum Msn NURS 2150 Metropolitan Community College

2. Selective Anatomy • 12 cranial nerves 31 spinal nerves • Neuron transmits impulses to facilitate movement or sensation • Meninges serve as protection of the brain and spinal cord • Bronca’s area in frontal lobe forms speech • Hypothalamus regulates water, appetite, temp • CSF: surrounds and cushions brain and cord

3. Physical assessment • Orientation • LOC • Memory • LTM (DOB) • STM (mode of transportation to hospital) • Immediate memory (repeat 3 words after 5 minutes) • Attention • Serial 7 test • Language/copying • Follows simple commands • Cognition • Current events

4. functional Assessment • Appearance • Speech • Motor function • Family history • Ethnicity • Diet • ADLs • Right handed or left handed • Brain injury is more pronounced in dominant hemisphere

5. Sensory assessment • Pain and temp • Cotton ball vs paper clip • Cold vs warm • Touch • Pt closes eyes and you touch hand etc and then have them touch where you touched ABNORMAL FINDINGS • Propioception-position sense below injury • Contralateral- loss of sensation in opposite side of body affected

6. Motor assessment • Hand grasps • Foot strength • Arm drift • Coordination • Gait • Balance • Reflexes ABNORMAL FINDINGS tremors, weakness, paralysis, jerking muscles

7. Rapid assessment • Glascow coma scale: eye opening, motor response, and verbal response • painful stimuli • Supraorbital pressure • Sternal rub • Mandibular pressure • Trapezius squeeze • LOC • Decortication-hands/arms turned in • Decerebration- hands/ arms turned out • Pupil assess • Response to light

9. The GCS is scored between 3 and 15, 3 being the worst score, and 15 the best. • It is composed of three parts: Best Eye Response, Best Verbal Response, Best Motor Response • When doing a neuro assessment it is important to watch for trends indicating a decreasing LOC. • Keep in mind that when patients have ingested alcohol, mind altering drugs, have hypoglycemia or shock with a systolic BP <80, the GCS may be invalid. • 9 to 12 is a moderate injury • 8 or less is a severe brain injury. •   7 or less = Coma

10. A client has a 5 on the Glasgow Coma Scale. When assessing this client, the nurse would expect what level of consciousness?

11. That was review from nurs 2520 and A&P • This is testable material.. So read CHAPTER 20

12. Seizure: abnormal sudden, excessive, uncontrollable electrical d/c of neurons w/in the brain that may result in altered LOC, motor/sensory ability, and/or behavior. No known cause but may be from tumors Seizures/Epilepsy

15. Tonic-Clonic: lasts 2-5 minutes Rigidity/stiffening arms/legs and Loss of Consciousness cyanosis excess drooling Tonic: loss of consciousness, muscle contraction and relaxation Clonic: rhythmic jerking, may bite tongue, incontinence Post seizure lethargy Absence: more common in kids, runs in families, blank staring, loss of consciousness (resembles daydreaming) Myoclonic: brief jerking or stiffening, symmetric or assymetric movement Atonic (akinetic): sudden loss of muscle tone, lasts for few seconds confusion after seizure. Partial: begin in one part of cerebral hemisphere, most often in adults and are less responsive to medical treatment Complex Partial: blacks out for 1-3 minutes and automatisms present (lip smacking, picking), amnesia after seizure,temporal lobe most affected Simple partial: remains conscious, senses unusual sensation, smell, or pain before (déjà vu). Unilateral movement during seizure, and may have tachycardia, flushing, or psychic symptoms Idopathic: account for ½ of seizures, no known cause Types of Seizures

16. Metabolic disorders ETOH withdrawl Electrolyte disturbances Heart disease Altered gene function Defective genes for channels that regulate ions in/out of cell Myoclonus clients are missing cystain B protein Etc. Triggers Physical activity Stress Fatigue Alcohol or caffeine Certain foods Causes

17. Def: chronic disorder characterized by recurrent unprovoked seizure activity. May be caused from abnormality in electrical neuronal activity, abnormal transmitters, or both. Approximately 2 million people in the USA with epilepsy Epilepsy

18. can be defined as abnormal, uncontrolled electrical activity in brain cells. • Nerve cells transmit signals to and from the brain in two ways by • (1) altering the concentrations of salts (sodium, potassium, calcium) within the cell • (2) releasing chemicals called neurotransmitters (gamma aminobutyric acid). The change in salt concentration conducts the impulse from one end of the nerve cell to the other.

19. Primary or idopathic Not associated with identifiable brain lesion Secondary Most common cause is brain lesion, tumor or trauma Status epilepticus Prolonged seizures that last greater than 5 minutes or repeated seizures over the course of thirty minutes. Causes: Med withdrawl Infection Acute alcohol withdrawl Head trauma Cerebral edema Metabolic disturbances Types of Epilepsy

20. CONVULSIVE STATUS EPIEPTICUS IS A NEUROLOGICAL EMERGENCY AND MUST BE TREATED PROMPTLY AND AGGRESSIVELY. Call 911or staff emergency Get airway established if needed by RT, Anesthesia O2 as needed Establish large bore IV access Start NS Get ABGs Transfer to ICU

21. Teach importance of taking meds as prescribed Promote balanced diet, rest, and stress reduction techniques Instruct pt. to keep a seizure diary to identify causative factors Education of seizure/epilepsy patient

22. Preicteral phase: aura present.. The first phase involves alterations in smell, taste, visual perception, hearing, and emotional state. This is known as an aura, which is actually a small partial seizure that is often followed by a larger event. Ictus: The seizure.. There are two major types of seizure: partial and generalized. What happens to the person during the seizure depends on where in the brain the disruption of neural activity occurs. Postictal state: The period in which the brain recovers from the insult it has experienced. Drowsiness and confusion are commonly experienced during this phase. the period in which the brain recovers from the insult it has experienced Phases of seizures

23. Nonsurgical Antiepileptic drugs Seizure precautions During: Protect the client from injury Do not force anything into mouth Turn client to side Loosen restrictive clothes Do not restrain After Take vitals Perform neuro checks Keep on side Allow rest document Teach family Info about disease Info about medication Support groups available Teach about alcohol avoidance To investigate state laws pertaining to driving and working with machinery Care of seizure client TREATMENT

24. Vagal nerve stimulation For simple or complex partial seizures Stimulating device is surgically placed in the left chest wall with a lead wire on the vagus nerve Activates with hand held magnet Corpuscalostomy Used for tonic-clonic seizures For those not candidates for other surgical procedures Sections of the anterior and 2/3 of the corpus collosum are created to prevent neural discharges Surgical treatment

25. Risk for falls Ineffective coping Risk for ineffective breathing Nursing diagnosis

26. HUNTINGTON’S DISEASE • Formerly huntington’s chorea • Hereditary • Transmitted as an autosomal dominant trait at time of conception • 25000 people in usa have • 2 main symptoms are progressive mental status changes and choreiform movements (rapid, jerky) in the limbs trunk and face

27. No known cause • No known treatment • Only prevention is to not have children • Antipsychotics and monoamine depleting agents used to manage movement • TX: PT, OT, speech therapy, meal planning by dietician, HHC, social work to line up community resources

28. Osteoporosis

29. Metabolic condition • Bone demineralizes • Easy to fracture • Wrist, hip, and vertebrae are most affected

30. Osteopenia: low bone mass • Osteoclasic: bone resorption • Decreased bone mineral density • 40-45% loss in women throughout lifespan • Trebecular (Spongy bone) is lost first • Then Cortical (compact bone) lost 2nd • Pathophysiology is unknown

31. classes • Generalized:involves many structures • Primary: more common • Post menopausal women • Men in 60s-70s • seconday • Regional: limb involved • r/t fx, injury, paralysis, joint inflammation • Immobilization greater than 8-12 weeks • Weightless environment (astronauts)

32. Health prevention • Teach about exercise • Teach about diet rich in calcium • Teach about bone health • Teach about safety

33. Assessment • Risk for falls • Head to toe assessment • Inspect and palpate vertebrae • Assess pain • Assess for fallophobia • No definitive lab tests • Bone scan to check density

34. Nursing diagnosis • Risk for falls • Impaired physical mobility • Acute or chronic pain

35. Interventions • Client education is #1 • Hormone replacements • Calcium supplements • Multivitamins • Diet • Fall prevention • Exercise • Pain management • Braces

36. Osteomalacia • Softening of the bone tissue • Inadequate mineralization of osteoid (mature compact and spongy bone) • Vitamin D deficiency is a key player • Similar characteristics with osteoporosis • Rare in USA • Prevent with vitamin D, sun exposure, and diet

37. s/s: early stages : nonspecific • Muscle weakness • Bone pain • Hypophosphatemia • Hypocalcemia • Generalized bone tenderness

38. Paget’s Disease

39. Metabolic disorder of bone remodeling • Bone deposits that are weak, enlarged, and disorganized • Phases: • Active increased osteoclasts cause massive bone destruction • Osteoclasts are multinuclear • Mixed • Inactive 2nd phase • New bone becomes sclerotic and very hard • Osteoclasts return to normal amount • 2nd most common bone disease • Most common sites are vertebrae, femur, skull, sternum, and pelvis • Unknown cause

40. Assessment • 80% asymptomatic • Assess past history of fractures, skin color and temp, gout, hyperparathyroidism, lethargy, hyperuricemia • Pain that is aching, deep, poor description • Pain worsens with weight bearing and pressure • Pain most noticeable at nite or at rest • Arthritis at infected joints • Assess posture, gait, and balance • Assess vision, speech, and swallowing, hydrocephalus, • Neoplasm is the dreaded complication

41. Diagnostics • Serum alk phosphate • Those treated for paget’s need ALP drawn 3-4 times/year • Urine hydroxyproline • Shows bone collagen turnover and degree of severity • Calcium levels are normal or elevated • Increase noted in uric acid • May initially be thought to be gout • X-rays, CT, MRI, bone biopsy

42. Treatment • Drugs for pain relief • Drugs to decrease bone resorption • Calcitonin (thyroid hormone) • Mithramycin (antineoplastic) • Biphosphanates • Heat therapy • Gentle massage • Exercise • PT • Diet • Osteotomy or joint replacement

43. osteomylelitis

44. Inflammatory process • Increase in vascularity and edema • Vessel becomes thrombosed once inflamed • Ischemia is next • Then necrosis • Sequestrium forms and retards bone healing

45. Categories • Exogenous: infection enters from outside • Endogenous: infection enters from inside • Contiguous: results from skin infection • The most common offending organism is pseudomonas aeruginosa • Staph, salmonella are aslo culprits

46. s/s and assessment • Pain • Fever • Erythema • Heat • Swelling • Assess circulation • Assess for septic shock

47. Treatment • Contact precautions • IV antibx therapy • PICC line • Use sterile techniques • Pain meds • Hyperbaric oxygen therapy • Bone grafts • Muscle flaps • Amputations

48. Bone tumors

49. Chondrogenic • Osteochondroma: most common, benign, tumor…onsets in childhood, grows until skeletal maturity..has a bony stalk like appearance..may become malignant • Chondroma: lesion of mature hyaline cartilage of the hand and feet. Ribs, sternum, spine, and long bones can also be affected…can get at any age or gender

50. Osteogenic • Osteoid osteoma: pinkish granular appearance..any bone affected..femur and tibia most affected • Osteoblastoma: affects vertebrae and long bones..large in size and lies in spongy bone..reddish granular appearance • Giant cell tumor: origin unknown..aggressive and extensive..affects women 20s-30s