Adult II- Neuro Exam 4

• Brain
• Spinal cord

• Nerves
• Ganglia

cluster of nerve cells all around the body not just the brain

• Consists of the brain & spinal cord
• Meninges

• Layers that protect the brain & spinal cord
• Pia matter- inner most layer
• Arachnoid- middle layer
• Dura mater- outside

Functional unit of the brain

• Cell body
• Axon
• Synapse
• Dendrites
• Myelin sheath

• Via chemical and electrical signals (called action potential)
• Signals travel down the neuron
• At the synapse, they reach the gap between the 2 neurons (synapse to synapse)
• Receiving neuron may ‘accept’ or ’deny’ the message.

• Cranial nerves
• Spinal nerves
• autonomic nervous system

fight or flight

rest and digest

Only One Of The Two Athletes Felt Very Good Victorious And Healthy

Some Say Marry Money But My Brother Says Big Brains Matter Most

• olfactory
• sensory=smell

• optic
• sensory- visual activity

• oculomotor
• motor= eye movement and pupil dilation

• trochlear
• motor= vertical eye movement

• trigeminal
• sensory- facial sensation
• motor facial expression

• abducens
• motor- lateral movement of eyeballs

• facial
• sensory- taste
• motor- facial expression

• vestibulocochlear/auditory
• sensory- hearing and balance

• glossopharyngeal
• sensory- taste
• motor- swallowing

• Vagus
• sensory- sensation in throat and visceral muscles, motor- vocal cords, peristalsis

• Accessory
• motor head and shoulder movement

• Hypoglossal
• motor tongue movement

• 31 pairs
• Cervical (8)
• Thoracic (12)
• Lumbar (5)
• Sacral (5)
• Coccygeal (1)
• Transmission is from brain and spinal cord to the body.
• If you have a breakage every pair below the injury will also be affected

• Regulates activities of internal organs
• Made up of 2 systems
• Sympathetic (fight or flight)
• Parasympathetic (rest & digest)

• Pain
• Seizures
• Dizziness
• nausea/ vomiting
• Muscle weakness/ gait change
• Sensation changes (numbness/ tingling)

• Family history
• Family history
• Current medications- side effects can resemble neurological conditions.

• What has changed?
• How long since the change?
• Any causing factors?
• Need to know baseline to know changes!

• Head to toe
• Cranial nerves
• Muscle strength/ weakness
• Gait (Romberg test)
• Reflexes- deep, superficial and pathologic(ex: Babinski reflex in adult)

• Level of consciousness
• Thought content.
• Glasgow coma scale (GCS)
• Language ability- ability to understand what’s being said to you AND to be able to articulate their thoughts
• NIH- Stroke scoring system

Stand in strait line with their eyes open, and their arms down then have them close their eyes and see if they can hold their posture for about 30 seconds if they can’t that is a failure or impaired proprioception

• Eye opening
• Verbal response
• Motor response
• 3 (worst score)
• 15 (best score)
• Low GCS is bad

• 11 categories of assessment stroke scoring
• 0 no stroke symptoms
• 1-4 minor stroke
• 5-15 moderate
• 16-20 moderate-severe
• 21-40 severe stroke
• Low NIH is good

• 4= Spontaneously
• 3= to speech
• 2= to pain
• 1= no response

• 5= oriented to time person and place
• 4= confused
• 3= inappropriate words
• 2= incomprehensible
• 1= no response

• 6= Obeys command
• 5= Moves to localized pain
• 4= Flex to withdraw from pain
• 3= Abnormal flexion
• 2= Abnormal extension
• 1= no response

• Narrow computerized xray beams produce a more detailed picture than a standard x-ray
• Looks at bones, muscles, organs, masses, lesions, and vessels
• Must keep head completely still for imaging- Important patient teaching
• Can be with or without contrast dye
• Low-emission of radiation
• Does not show acute ischemic stroke- but still give them a CT to make sure there is no bleeding

• magnetic resonance imaging
• Uses a powerful magnetic field to get detailed imaging
• Can be with or without contrast- different type than CT usually less harmful but still need to educate them to flush with plenty of fluids
• Looks for strokes, tumors, traumatic injuries, MS progress, abnormalities

takes 45mins-1hr, they need to be still, be aware that magnet does not turn off just because the test is done

• Uses radioactive tracer to identify disease, injury, and organ function
• Measures blood flow, tissue composition, and brain metabolism

• Detailed, 3D map of brain blood flow and consistency
• Contraindicated in pregnant women

• Involves a catheter, x-ray, and contrast dye to look at brain blood vessels
• Catheter is typically inserted via femoral artery (“groin stick”) to monitor for s/s hematoma or bleeding after.
• Since dye is used, monitor kidney function (BUN/ creatinine) pre and post procedure
• Helps find aneurisms or atherosclerosis
• Can be more than just imaging you can fix the patient in live time as well

• Measures electrical activity of the brain
• Baseline measure with the patient laying still, quiet
• Stimulation is introduced to measure possible seizure

• Educate pt to try not to sleep until the test
• Do not take anticonvulsants, tranquilizers, or sedatives 48h prior to EEG
• Eating is allowed prior to EEG, but no caffeine, including chocolate or decaf!

• Needle inserted into subarachnoid space in lower back to aspirate cerebrospinal fluid (CSF)
• Space between L3 and L4 or
• L4 and L5
• Fluid should be clear and colorless
• ***keep patient in side lying position and educate to remain STILL
• Makes it easier for the physician get inbetween the vertebra

• Pressure measurement
• Fluid analysis
• Administer medications

• Educate pt to remain laying flat for 2 hours post-procedure
• Prevents spinal headache and allows site to heal and close

• Spinal headache
• Herniation
• Abscess
• Hematoma
• meningitis

• Sudden & uncontrolled electrical disruption in the brain
• Can cause changes in behavior, movement, feeling, LOC

• Focal
• Generalized
• Unknown onset

• Involve 1 part of brain
• “Partial seizures”
• Can be simple (with awareness) or complex (impaired awareness)

• Involve the whole brain
• Can be tonic-clonic (grand-mal) or absence (petit-mal)
• Focal seizure can turn into generalized

• “Unclassified”
• Incomplete data surrounding the event

• Allergies
• Brain tumors
• CVA/stroke
• Infection
• drug/alcohol withdrawal
• Fever (childhood)
• Head injury
• Hypertension
• Hypoxemia
• Metabolic and toxic conditions- kidney injury, pregnancy, low Na low K etc

• Menses decreases seizure threshold (higher chance)
• Anti Seizure meds can decrease birth control effectiveness
• Increased risk of fetal abnormalities if pregnant r/t meds
• Increased risk of osteoporosis r/t abnormalities meds* (phenytoin)

• Seizures can be r/t CVA, aging differences, dementia
• Higher chance of having med toxicity
• Cost of drugs can lead to decreased compliance

• Unprovoked & recurring seizures
• Typically starts in childhood
• Primary (unknown cause)
• Secondary (known cause, such as a brain tumor)

A medical emergency where the seizure lasts >(greater than) 5 mins or serial seizures without full recovery between

fever, infection, not taking anti-seizure medications

• medications to stop seizures (diazepam/ lorazepam typically)
• Nursing care: same as any seizure, focusing on safety

• “Psychogenic seizures”
• “Non- epileptic seizures”
• Clinical events that resemble a seizure but are not
• Typically a psychological cause (severe stress)
• anticonvulsant/ antiseizure medications do not work
• Video EEG monitoring is the gold-standard for diagnosis would look normal, no changes with pseudo seizures

• Common anti seizure medications
• Clonazepam (Klonopin)
• Lamotrigine (Lamictal)
• Levetiracetam (Keppra)
• Phenytoin (Dilantin)
• Valporic Acid (Depakote)

• Dizziness
• Drowsiness
• Lethargy
• Behavior changes
• Irritability

• Skin rash
• Herpatoxicity
• Nephritis
• Leukopenia
• Bone marrow failure/ bone loss ****
• Gingival hyperplasia (long term use of phenytoin)*******

• History
• Triggers
• Medications
• How long since last one?

• SAFETY!!
• Observe
• record

• Circumstances surrounding
• Aura?
• Gaze and head position
• Type of movements
• Size of pupils
• Eyes open/closed
• Incontinence
• Duration
• LOC

• paralysis/ weakness
• Ability to speak
• Cognitive state
• Side-lying position to prevent vomiting/aspiration****

• Cushion head
• Position pt on their side
• suction/oral air-way open
• Bed in lowest position
• Padded side rails
• Loosen clothing
• Decrease in stimuli
• Medication administration (IV diazepam/ lorazepam)

• Reorient if needed
• Monitor for aspiration, hypoxia, vomiting
• Let them sleep!
• Know they may be agitated

• Avoid dietary stimulants (caffeine, coffee, even decaf or chocolate)
• Avoid environmental stimulants (flashing lights)
• No driving until 6 months free from seizures
• Avoid overwhelming fatigue & get proper rest
• Avoid alcohol and drug use
• Take your anti seizure medications as prescribed!

Headaches are a symptom, not a disease itself

• Primary headache – no organic cause is found
• Secondary headache - symptom related to another disease process or cause

• NSAIDs- ibuprofen, toradol, naproxen
• Acetaminophen
• Sumatriptan- Imitrex, mod-severe
• Topiramate- Topamax, migraines
• Gabapentin- migraine prevention
• Aspirin
• Caffeine

• Manage stress
• Relaxation
• Medication
• Exercise
• Environmental: Quiet, Dim or dark lightning, Behavior: Get enough sleep, Elevate head of bed, Cold compress to head/neck
• Other: Acupuncture, Daith piercing, Botox injections

• Alcohol
• Foods with tyramine- aged, processed foods and artificial sugars
• Processed foods
• Artificial sugars
• Fasting periods

• Concussion
• Chronic traumatic encephalopathy (CTE)
• Traumatic brain injury (TBI)

• Temporary loss of neurologic function
• No apparent structural damage to brain
• “Mild TBI” (traumatic brain injury)
• Typically from direct blow or blast
• Monitor for behavior changes- tells us if the concussion is getting worse
• Grade of concussion relates to the duration of the mental status abnormality

• Hazy, foggy, or groggy head feeling
• Nausea and vomiting (1st sign)
• Headache or pressure in the head
• Dizziness or balance issues
• Feeling confused or trouble remembering things

• Repeated concussions leading to permanent brain damage
• Most common in contact sports (football, boxing)
• Similar to alzheimer’s disease
• Imaging shows brain atrophy
• What percentage of former NFL players have CTE on imaging? 99%

• Brain dysfunction caused by an outside force (blow/impalement)
• May have immediate or delayed symptoms
• Levels of TBI range from mild – severe
• There are many types, most commonly concussion, contusion, hemorrhage

• Brain suffers traumatic injury →
• Brain swelling or bleeding increases intracranial volume →
• Rigid cranium allows no room for expansion of contents so intracranial pressure increases →
• Pressure on blood vessels within the brain causes blood flow to the brain to slow →
• Cerebral hypoxia and ischemia occur →
• Intracranial pressure continues to rise. Brain may herniate →
• Cerebral blood flow cesses

• Meningitis
• encephalitis

• Inflammation of the meninges
• Can be bacterial (septic) or viral (aseptic)
• bacteria/virus enters the bloodstream, then crosses blood-brain barrier, inflames meninges and thus increases ICP

• Dense community groups
• Season- winter & early spring
• Tobacco use
• Unvaccinated
• Soon after infection- Upper respiratory infection, Otitis media/ ear infection, Mastoiditis, immunodeficiency

• Headache (steady, severe, throbbing)
• Chills & fever (high fever throughout illness)
• Cognitive impairment and/or seizures
• neck stiffness and immobility (nuchal rigidity)
• Light sensitivity (photophobia)
• Positive Kernig and/or Brudzinski sign

• Patient starts out lying flat then we bring their bent leg upward and then attempt to straighten the leg beyond 135 degrees causes pain
• This techniques stresses the inflamed meninges area causing pain

pull their neck up or chin to chest causes pain so they bring their knees upward to try and relieve that pain

• Lumbar puncture: WBC (high), Protein (high), Glucose (low)
• Imaging: CT, MRI
• Labs: Blood cultures

• IV fluids
• Antibiotics- most common vancomycin and cephalosporin
• NSAIDs/Steroids- most common steroid dexamethasone
• Isolation: droplet (protect yourself FIRST)
• If seizures, treatment- most common phenytoin
• If increased ICP, treatment
• Prevention! Vaccine at 11/12 years & booster at age 16

• Visual impairment
• Deafness
• Seizures
• Paralysis
• Hydrocephalus
• Septic shock
• Death

• Inflammation of the brain itself
• Typically caused by a virus (HSV herpes most common)
• Can be vector-borne virus
• Arbovirus- mosquitoes & ticks
• West nile virus- mosquitoes

• Fever
• Headache
• confusion/hallucinations
• Seizures
• Dysphagia
• Altered LOC
• Arbovirus- flu like symptoms

• Herpes exposure
• summer/fall mosquito presence
• Tropical areas with mosquitoes

• Lumbar puncture:Pressure (high), Glucose (low), Protein (high), Virus in CSF*
• Imaging: MRI, EEG

• Control seizures
• Control ICP(intercranial pressure)
• Herpes- antivirals (acyclovir)
• Arbovirus- no meds just symptom management

• Bug spray
• Wear long, covering clothing
• Avoid being around standing water
• Use window screens

• Multiple sclerosis (MS)
• Myasthenia gravis (MG)

• Progressive disease where the myelin sheath (protective layer) of the nerve cell disintegrates and causes impaired transmission of nerve impulses
• Over time, nerve cells die as a result and cause lesions or “holes” (scarred areas in brain) Sclerosis means scaring and those are the lesions we see in the brain
• Remissions and exacerbations that ultimately cause permanent, irreversible damage
• No known cause

• Women
• Age on onset 25-35 years old
• Northern united states
• Having first relative or sibling with MS

• Fatigue
• Weakness (#1 symptom)
• Numbness
• Ataxia (difficult coordination)
• Bowel/bladder/sexual dysfunction
• Pain
• Loss of balance
• Visual disturbances
• Depression
• Dysphagia
• Paralysis

• No cure
• Supportive care
• Individualized treatment

• Reduce frequency, duration of relapse & thus lesions on MRI
• Rebif
• Betaseron
• Avonex
• Side effects: flu like symptoms, potential liver damage, fetal abnormalities, depression
• Many new meds all the time!

• Methylprednisone
• Prednisone

• Muscle spasms- Baclofen
• Fatigue- symmetrel
• Ataxia or nerve pain- gabapentin
• Bladder spasms- dantrium

• Avoid excessive heat
• Good sleep & nutrition
• Daily schedule to minimize fatigue & conserve energy
• Avoid alcohol and smoking
• Exercise!
• Use an assistive device if necessary
• Cough, deep breathe
• Bowel and bladder training
• Diplopia: eye patch or covered lens

• Chronic, autoimmune, neuromuscular disease causing weakness in skeletal (voluntary) muscles
• Acetylcholine receptors become blocked with antibodies (autoimmune) & thus block voluntary muscle contract
• Because of this, periods of movement make it worse and periods of rest makes it better
• These antibodies are produced by the thymus
• Two types- generalized and occular

• Women 20-40y/o*
• men> 50 years old
• NOT inherited
• NOT related to ethnicity or race

• Ocular muscles affected first (diplopia & ptosis)
• Flat facial affect
• Dysphonia
• Dysphagia
• Extremity & muscle weakness
• Weak intercostal muscles

• Emotional stress
• Infections
• Surgery
• Vigorous physical activity
• High or low environmental temperatures
• Certain medications
• Pregnancy and menstrual periods

• Tensilon test*
• Blood test for antibodies
• Thymus MRI (enlarged)
• EMG

tensilon drug is given to pt IV, and within 30 seconds patient should have less muscle weakness and eyes change from abnormal eyelid opening to normal Drug is essentially preventing the breakdown of acetylcholine

• Goal: decrease or remove antibodies
• IVIG- IV immunoglobulin
• Prednisone/ methylprednisolone
• mestinon/ pyridostogmine
• Plasma exchange
• Thymus removal- in some pts will cure them of the disease

• Cholinesterase inhibitor
• Affects chemicals involved in nerve/ muscle communication
• Must be taken at the same time each day
• Side effects: N/V/D, twitching/muscle weakness, diaphoresis, asthma or bronchitis exacerbation

• A medical emergency when the intercostal muscles that are weakened by the disease and cannot inflate the lung properly.
• Respiratory distress/ arrest
• Dysphagia
• Dysarthria
• Ptosis
• Weakness
• Patients are typically intubated and/or on a ventilator, if they do not get better it will lead to total collapse of intercostal muscles leading to death