What are neurotransmitters?
chemical messengers of the nervous system
Name two NTS
- Acetylcholine (ACh)
- Norepinephrine (NE)
ACh vs NE
- ACh-excitatory NTS
- NE-excitatory and inhibitory
nerves that transmit impulses through the release of ACh
Excitatory or Inhibitory
nerves that transmit impulses through the release of NE
Where do you find cholinergic receptors?
viscera, skeletal muscle cells and adrenal medulla
Where do you find Adrenergic receptors?
- blood vessels
*all target organs stimulated by the Sympathetic except for the heart
Two types of Adrnergic nerve receptors
Alpha and Beta
Describe Alpha Adrenergic receptors
they bind to alpha receptors to stimulate arterial vasoconstriction
Describe Beta Adrenergic Receptors
- binding to beta receptors inhibits 2 types of responses...
- Beta 1-receptors in heart to regulate rate and force of contraction
- Beta 2-receptor cells of the lungs, arteries, liver and uterus
Left vs. Rt Hemispheres of the brain
Left controls language
Rt controls nonverbal perceptual functions
sorting, processing and relaying station of the brain
- regulation of temp
- water metabolism
- emotional expression
- sleep wake cycle
center for auditory and visual revlexes
controls heart rate, blood pressure, respiration and swallowing
- coordinates skeletal muscle activity
- maintenance of balance
- controls fine motor movements
What are the only things that can pass through the blood brain barrier
- some amino acids
- carbon dioxide
What is blocked by the blood brain barrier?
- some toxins
- most antibiotics
What part of the brain is responsible for providing emotional and behavioral responses to environmental stimuli?
Reticular Activating System is responsible for
relaying sensory input from all body systems to the brain
alert and responsiveness
What sort of messages to ascending pathways transmit?
- crude touch
What sort of messages do descending pathways transmit?
- sensations of fine touch, position and vibration
- purposeful movements
- stimulate/inhibit muscle actions
- muscle tone
- gross body movements
Somatic reflexes result in
skeletal muscle contractions
Autonomic reflexes result in
activate cardiac and smooth muscle and glands
What does the ANS regulate?
- the bodies environment...
- visceral motor system:
- cardiac muscle
- smooth muscle
What is the primary controller of the ANS?
Reticular formation in the brain stem
What part of the nervous system do ACh and NE effect?
SNS stimulation causes....
fight or flight
- dilated pupils
- increased mental alertness
- inhibits secretions (dry mouth) and diaphoresis
- decreased urine output
- Increased blood clotting
What does the sympathetic nervous system do to the heart and lungs
Causes dilation of arteries and increases the rate and force of the contraction....arteries vasoconstrict
What does the sympathetic system do to the liver
- increases the release of glucose by the liver
- increasing the metabolic rate
What does the sympathetic nervous system do to the blood vessels of the abdomen and skin?
What does the parasympathetic nervous system cause?
- constriction of pupils
- stimulation of glandular secretions
- constriction of bronchioles
- increased peristalsis and secretion of GI fluid
**Basically runs our body during non stressful times
What is MS?
it's a degenerative disorder of the CNS characterized by the demyelinization of nerve fibers of the brain and spinal cord myelin sheath.
What's affected with MS?
the motor and sensory conduction pathways of the CNS
- person becomes uncoordinated (trips)
- and has a muttled brain
How do you get MS?
- have a susceptible gene
- infection by a slow virus
- immune problem
Who's most likely to get MS?
A European American woman 20-50 years old
What triggers a MS exacerbation?
- Infections-URI or UTI
- Delivery after pregnancy
- Change in climate
What's the problem with MS?
impulses don't move from nerve to nerve
Signs and symptoms of MS
- scanning speech
- muscle spasms
- spastic/hypotonic bladder
- problems with airway clearance
- problems with chewing/swallowing
Cognitive changes for a person with MS
Can be severely fatigued
Changes are mainly seen in short term memory, attention, processing information, word finding and visual perception.
NO CHANGE IN INTELLIGENCE
What meds do you use MS acute exacerbations?
Side effects for MS patients on Corticosteroids, ACTH, Methyloprednisolone and Prednisone
Patient teaching for MS patients on Corticosteroids, ACTH, Methyleprednisolone, Prednisone
- Restrict fluid intake
- Don't stop abruptly
- Know drug interactions
3 Meds used to prevent MS exacerbations
Side effects of MS drug Betaseron
- Flu like symptoms
- local skin rash
Labs to watch with Betaseron
Side effects of Copaxone for MS
- Skin reactions
- chest pain
Side effects for Novantrone for MS
- cardiovascular disease
Keep in mind with Novantrone for MS
there is a lifetime dose limit because of cardiotoxicity
Monitor CBC and LFT every month
Patient teaching for Betaseron and Copaxone for MS
How to perform self infection and report side effects
Patient teaching for Novantrone for MS
- Need regular monitoring and follow up
- Talk with HCP prior to getting immunizations
- Maintain adequate fluid intake
- **Urine may turn blue-green**
2 Meds given to MS patients for Urinary Retention (Flaccid Bladder)
Urecholine and Prostigmin
Side effects of Urecholine and Prostigmin for Flaccid Bladder/Urinary retention
- Hypotension and cardiac dysfunction
- Peptic Ulcers
Patient teaching for Urecholine and Prostigmin for Flaccid Bladder/Urinary Retention
Consult HCP before using any other meds....including OTC
2 meds used for Spastic Bladder (Urinary frequency and urgency)
Side Effects of Probathine and Ditropan used for Spastic Bladder/Urinary frequency and urgency
- Anticholinergic-cant see, pee, spit, poop
- Urinary retention....if take too much
Patient teaching for Probathine and Ditropan for Spastic Bladder/Urinary frequency and urgency
Consult HCP prior to taking any other meds..
**If you take sleeping aids or anithistamines could possibly have a potentiated effect
Who is contraindicated for taking Probanthine and Ditropan for Spastic Bladder/Urinary frequency and Urgency
- Hx of glaucoma
- cardiac dysfunction
- Intestinal obstruction
Drugs for muscle spasms
Similar side effects and patient teaching for all muscle relaxers
PT. Teaching-avoid driving, no CNS depressants and don't drink
Whos contraindicated to take valium
person with glaucoma
Patient teaching for valium
- can be addictive
- avoid long term use
What don't you take if you are on valium?
Who shouldn't take Baclofen?
person with history of hypersensitivity and renal damage
*don't take if you have a seizure disorder
How do you take Baclofen
with food or milk
What will happen if you abruptly stop taking Baclofen
Who should use Dantrium cautiously?
anybody with a history of respiratory or cardiac dysfunction
Dantrium can cause
What will happen if you take Dantrium or Zanaflex and take tranquilizers or drink alcohol?
Prior to starting Dantrium you must....
get a baseline LFT
Who should take Zanaflex cautiously?
- persons with liver or renal disease
How do you take Zanaflex
with small meals to help with nausea
Patient teaching for Zanaflex
change positions slowly cuz of orthos
Whats a new drug to treat relapsing forms of MS? How does it work?
- blocks access for lymphocytes to the CNS...
- KILLS T CELLS
Why do persons with MS get PT/OT?
- ROM exercises to prevent contractures
- gait training
- aids for ambulating
- assistive devices
- techniques to maintain indep. with ADL
- braces and adaptive equipment
Exercise OT/PT with MS is used to...
increase coordination and train patient to substitute unaffected muscles for impaired ones.
*lots of exercises done in water
How does spasticity with MS get treated?
- antispasmodic drugs
- surgery (neurectomy, rhizotomy, cordotomy)
- dorsal-column electric stimulation
How are tremors treated with MS?
if unmanageable with drugs...treat with thallamotomy or deep brain stimulation
When a person has an acute exacerbation from MS what do we do?
- they will probably be on bedrest and be immobile...
- so to prevent complications reposition/skin care
- toileting/peri care
Nutritional therapy for a person with MS
- mega vitamins (cobalamin and vitamin c
- low fat
- gluten free
- roughage/taw vegetables
How do you overcome nystagmus?
patch an eye
MS patients need to adjust caloric intake....how?
increase cuz need more due to spasticity
Later stages MS and communication....
coding yes or no with eyes....allow time for responses
What happens to airways with MS
becomes inadequate so suctioning may be required and IS used to help with respiratory muscles
What's Myasthenia Gravis?
an autoimmune disease of the neuromuscular junction that is characterized by fluctuating weakness of certain skeletal muscle groups
How does MG work?
Antibodies to ACh attack the receptors causing a decrease in the number of ACh receptor sites at the neuromuscular junction....prevents ACh molecules from attaching and stimulating muscle contraction
Age range for people to get MG
10-65...peak age for women is 20-30
MG is usually caused by 2 things....
Thymic abnormalities or hyperplasia (increased cell production)
2 Anticholinesterases to treat MG
How do Neostigmine and Pyridostigmine work?
they at at the neuromuscular junction and allow ACh to concentrate at the receptor site promoting muscle contractions
What are you concerned about after a Thymectomy?
- focus on preventing complications and controlling pain
- at risk for pneumothorax
How long for remission to occur with a thymectomy?
can be several years
Plasmaphoresis and MG
- it is used for patients with respiratory problems
- need a CVC or AV fistula or graft to do
*removes anti acetycholine antibodies to improve sever muscle weakness, fatigue and other symptoms
Why do people with MG have breathing issues?
- cuz poor cough mechanisms
- decreased cage expansion
- diminished diaphragm movement
- decreased expiratory effort
How do you help a person with MG with their respiratory issues?
- encourage hydration; percussion postural drainage and suction
- TCDB q 2h
- Semi Fowlers
- check lung sounds, rate and character
- Pulse ox as needed
Why does a person with MG have impaired swallowing?
weakness of the laryngeal and pharyngeal muscles involved with swallowing.
*Need to make changes with foods cuz at risk for aspiration
Home care goals for a person with MG
- prevention/recognition of crisis situation
- understanding the disorder and coping with the physical, psychosocial problems and impaired self care abilities
When doing a neuro check....what is the progression if the patient isn't responding?
- speak....get louder
- supra orbital pressure
- trapezius squeeze
- sternal rub
What is the first thing to change in a person if there is a neurological problem?
start acting confused or disoriented
What part of the brain is in charge or alertness and persons arousal?
RAS....and it's connection to the thalamus and cerebral cortex
This is the lowest level of consciousness and observation is centered around the patients ability to respond to verbal/noxious stimuli appropriately
What part of the brain is concerned with awareness?
It is a higher functioning test which deals with orientation to person, place time and pupose
Mentation, memory and attention span
state of drowsiness or inaction, patient needs increased stimulus to be awakened
confusion with disordered perceptions and decreased attention span.
marked anxiety with motor and sensory excitement
a duller difference to external stimuli exists and response is minimally maintained
can be aroused only by vigorous and continuous external stimuli
What's Glascow Coma Scale based on?
- eye opening
- verbal response
- motor response
It is a practice means of monitoring changes in LOC
Eye opening responses for GCS
- 3-To speech
- 2-To pain
- 1-No response
**record "C" if eyes closed by swelling
Motor responses for GCS
- 6-Obeys verbal commands
- 5-localizes pain
- 4-Flexion withdrawl
- 3-Flexion abnormal
- 2-Extension abnormal
- 1-No response
*Record best upper limb response
Verbal response for GCS
- 5-oriented x 3
- 4-conversation confused
- 3-speech inappropriate
- 2-sounds incomprehensible
- 1-no response
**Record "E" for ET tube and "T" for Tracheostomy
Where are 10 of the 12 cranial nerves located?
in the brain stem
Cranial Nerve assessment
- first time all should be assessed....
- after that 2-6, 9 and 10
Cuz they regulate pupil response, eye movement and protective mechanisms
Saying for Cranial Nerves
Oh, oh, oh, to touch and feel a guys veiny slimy hotdog
- spinal accessory
- tested with Snellen and Rosenbaum charts
- raise eyelids
- constrict pupils
- change eye lens shape
Which Cranial Nerve is used in PERRLA?
downward and inward eye movements
Facial Movement and Sensation
*inspect face for muscle atrophy and tremors
lateral eye movement
- facial expression
- secretion of saliva and tears
hearing and equillibrium
Weber and Rhine test
Speech, Swallowing and Gag Reflex
**Test to ID sour and bitter tastes and test gag reflex for ability to swallow
Speech, Swallowing and Gag Reflex
**Problems here after radical neck surgery
tongue movement for speech and swallowing
**test tongue strength with index finger when tongue is pressed against the cheek
**Evaluate quality of linqual speech sounds (l,t,d,n)
If you are testing swallowing which 2 cranial nerves are you assessing?
- Glossopharyngeal IX
- Vagus X
Which cranial nerves are tested together to tell you eye motion?
- III Oculomotor
- IV Trochlear
- VI Abducens
If you want to do a swallow test which cranial nerves involved?
Test muscle strength by asking the patient to....
push and pull against the resistance of your arm as it opposes flexion and extension of the patient's muscle...
Done at shoulder, elbow, wrist, hips, knees and ankles
**Note any weakness or asymmetry of strength between the same muscle groups of the right and left side
How do you test muscle tone?
by passively moving the limbs through their ROM, there should be slight resistance to these movements
involuntary spasm of muscles....tics/tremors
slow, writhing, involuntary movements of extremities
involuntary purposeless rapid motions
impairment of muscle tone
How do you test the cerebellum?
- Just look at their posture while standing and their gait
- Note the pace and rhythm of the gait and the arm swing
How do you test fine motor skills?
- Index Finger-Index Finger
Normal motor strength score
5/5....normal movement against gravity and resistance
4/5 Motor Strength
full ROM against moderate resistance and gravity
3/5 Motor Strength
full ROM against gravity only, NOT against resistance
Can hold hand up, but cant hold it up against resistance
2/5 Motor Strength
extremity can move...but not against gravity
**can roll but cant lift
1/5 Motor Strength
muscle contracts but extremity cant move
**spinal cord injury
0/5 Motor Strength
No visible or palpable muscle contraction or movement of the extremity
Test for Balance and Equillibrium
- when you push a patient they should sway mildly, but not have a loss of balance.
done with eyes open and closed
What's a normal Deep Tendon Reflex test?
- 0 is no response
- 4 is hyperactive
Used to assess for a brain or nervous disorder
- Pt. lays supine
- Stroke lateral-plantar aspect of the bottom of the foot with your thumbnail
After the age of 2 it is abnormal to have a positive result with dorsiflexion of the big toe and fanning of other toes
Tests to DX MS
- Cerebral Spinal Fluid
What do you need to know with seizure disorders?
- Precipitating factors?
- Neurologic Assessment
- Seizure description:onset, duration, frequency and postictal state
Diagnostic studies for seizure disorders
- CT, MRI, PET
Gerontologic considerations and neurological disorders
high incidence with elderly
Med problems that cause neurological disorders
Phenytoin...cuz is hard on liver and is metabolized in liver causing (antiseizure med)
Phenobarbitol and Primidone affect cognition
Collaborative Management and General patient education for MS...Goals and Plan
- achieve a good balance of exercise and rest
- eat nutritiously
- avoid the hazards of immobility(contractures/pressure ulcers)
- avoid exposure to infections
- know your meds for side effects, interactions and OTC reactions
Why is the thymus removed with Myasthenia Gravis patients?
cuz the thymus increases production of ACh antibodies which attack the ACh receptors not allowing ACh to bind to receptor sites.
When do you take Neostigmine for Myestenia Gravis?
30 minutes prior to meal time
Main issues of Myasthenia Gravis
- Ineffective Airway Clearance
- Impaired Swallowing
What causes Myasthenia Crisis?
this occurs from under medication or the body not responding to the medication.
Adjust or change meds...Tenselon?
What causes Cholingergic Crisis?
this occurs from over medication and allowing too much ACh to be present so muscles stop responding to ACh
S/S of Cholinergic Crisis....and what do I do?
- Worsening of Myasthenia symptoms
- Flaccid Paralysis
- Respiratory Failure
- Increased sweating and salivation
Give them Atropine
S/S of Myasthenia Crisis and what do I do?
- increased weakness or paralysis...especially of the diaphragm and chest muscles......
- respiratory failure
- severe ocular or bulbular symptoms
change meds... or go on Tenselon?
If a person has < or = an 8 score with Glasgow coma scale....what does this mean?
Why would a person have an elevated temperature with brain trauma?
they hypothalamus has probably been damaged
What's a widened pulse pressure? What does it mean with a head trauma person?
The SBP is increasing, but the DBP isn't.
What happens to the pulse as ICP advances?
Cranial Nerves...Sensory, Motor or Both
Some say marry money but my brother say big brains matter more
Positive result of Babinski means the person may have.....
- Brain Tumor/injury
- Spinal Cord Injury, defect or tumor