Exam #5 Flashcards
(105 cards)
1
Q
structures and fxns of nervous system
A
- central nervous system
- brain
- spinal cord
- crainal nerves I and II
- Peripheral Nervous system
- cranial nerves III and XII
- spinal nerves
- autonomic nervous system
2
Q
Neurons
A
- neurons
- primary functional unit
- characterized by: excitability (start impulse), conductivity (transmit impulse), and influence (ability to influence other neurons, muscle cells or glandular cells by transmitting nerve impulses to them)
- consists of: cell body, dendrites, axon covered by myelin sheath
3
Q
Glial cells
A
- provide support, nourishment and protection to neuron
- more numerous than neurons
- types:
1) microglia capable of phagocytosis
2) macroglia
A astrocytes: most abundant, phagocytosis of debris from injury, form the BBB
B oligodendrocytes: produce the myelin sheath
C ependymal: aid in secretion of CSF
4
Q
Regeneration and Impulses
A
- nerve regeneration (repair)
- attempt to grow back
- PNS more successful than CNS in regeneration
- nerve impulses affected by neurotransmitters
- acetylcholine: activates muscles, decreased in alzheimers disease and mysethenia gravis
- dopamine: affects mood, decreased in parkinson’s disease
5
Q
Cerebrum
A
- right and left hemispheres, 4 lobes
- frontal: high cognitive fxn, memory retention, voluntary eye movements, voluntary motor movement, speech in broca’s area
- temporal: integrates somatic, visual, and auditory data and contains wernicke’s speech area
- parietal: sensory and spacial
- occipital: sight
- gray matter on outer layers, white matter on inner layers
- basal ganglia: voluntary movements, learning
- thalamus: relays sensory and motor input to and from cerebrum
- hypothalamus: regulates endocrine and autonomic fxns
- limbic system: feeding and sexual behavior
6
Q
brainstem
A
- autonomic nervous system
- midbrain
- pons
- medulla: respiratory, vasomotor, and cardiac fxn
- nuclei of cranial nerves III and XII are in the brainstem
7
Q
cerebellum
A
- trunk stability and equilibrium
- coordinates voluntary movement
8
Q
peripheral nervous system
A
- all neural structures that lie outside the CNS
- spinal and cranial nerves, gnglia, and portions of ANS
- spinal nerves: dorsal (afferent) ventral (efferent), motor, sensory
- spinal cord is grey matter inside and white outside
- dermatomes: skin
- myotomes: muscle group inervated by primary motor neurons of single ventral root
- cranial nerves
- ANS: involuntary, cardiac muscles
- sympathetic: fight of flight
- parasympathetic: rest and digest, conserves energy
9
Q
cranial nerves
A
1 o s - olfactory: smell
2 o s - optic: vision
3 o m - oculomotor: eye movement
4 t m - trochlear: superior oblique muscle eye movement
5 t b - trigeminal: S = facial feeling, front of tongue; M = chewing
6 a m - abducens: lateral rectus of eye
7 f b - facial: M = muscles of expression and cheek; S = taste from anterior 2/3s of tongue
8 v s - Vestibulocochlear: hearing, balance
9 g b - glossopharyngeal: S = taste, posterior tongue; M = swallowing
10 v b - vagus: S = throat and abdoment; M = larynx and swallowing; heart, lungs, digestive system
11 a m - accessory: sternocleidomastoid and traps muscles, shoulder shurgs
12 h m - hypogloassal: muscles of tongue
10
Q
brain protection
A
- blood brain barrier: protects from harmful agents, lipid soluable agents enter easily, water soluable agents enter slowly
- skull: 8 cranial bones and 14 facial bones, foramen magnum (hole that brainstem goes through)
11
Q
vertebral column
A
- 33 vertebrae
- 7 cervical
- 12 thoracic
- 5 lumbar
- 5 sacral
- 4 coccyx
12
Q
genontologic considerations of nervous system
A
- CNS: loss of neurons, enlargement of ventricles, decreased brain weight/ cerebral blood flow/ CSF production
- PNS: decreased nerve conduction, decreased coordinated neuromuscular activity (affects blood pressure changes)
- decreased memory
- decreased sensory/neuromuscular fxn (body temp maintenance)
- decreased reaction time, taste, smell, sit, hearing (high pitch lost first), nigh vision, peripheral vision
13
Q
neuro assessment
A
- cerebral fxn: mental status, general appearance, cognition, mood/affect
- cranial nerves
- motor system: weakness, muscle tone, balance/coordination
- sensory system: touch, pain, position
- reflexes
14
Q
neuro diagnostic studies
A
- CT
- MRI and MRA
- PET and SPECT: metabolic activity, need IV, looks for blood flow, can catch dimentia
- ultrasound: patency and stenosis of vessels
- cerebral angiography: look for lesions or tumors in vessels
- lumbar puncture: r/o infection, look at CSF, look for menningitis, cancer cells
- myelogram
- EEG
- EMG
15
Q
lumbar puncture
A
- sterile technique
- increased intracranial pressure = no LP
- may feel pain down leg
- needle between vertebral bodies
- post: best rest, band aid, headache, band aid
16
Q
myelogram
A
- xray of spinal chors w contrast
- done on tilt table and moved during test
- post: bed rest, fluids, n/v
17
Q
cerebral angiography
A
- looks for tumors/lesions
- time-sequenced radiographic images
- hematomas, arterial spasms
- post: observe for bleeding
18
Q
electrographic studies
A
- EEG: brain elec activity
- Electromyography and nerve conduction studies: needles in muscles
- evoked potentials: nerve conduction
19
Q
Stroke risk factors
A
- non-modifiable: age, gender, ethnicity, family history
- modifiable: HTN (#1 cause of stroke), heart disease, smoking, diabetes, alcohol, obesity, sleep apnea, lack of exercise, poor diet, drug abuse = atherosclerosis
20
Q
Transient Ischemic Attacks (TIAs)
A
- transient neuro problems caused by ischemia without actual infarction
- a warning sign
- can have a variety of symptoms depending on where the blockage is
- symptoms usually last
21
Q
types of strokes
A
- Ischemic: 80-90%
- thrombotic: most common cause, usually have had some TIAs prior, S/s no decrease in LOC, symptoms progress for 72 hours
- embolitic: usually have a cardiac history, less likely to have had any warning signs, recurrence is common, s/s sudden onset of severe symptoms, usually remain conscious, atherosclerosis
- hemorrhagic: 10%
- intracerebral: rupture of vessle, increased intracranial pressure, much worse is pt is on blood thinners, poor prognosis, usually caused by HTN, s/s sudden onset of severe symptoms with rapid progression, severe headache, n/v
- subarachnoid: rupture of anyerysm, could be from trauma or cocaine use, s/s silent killer, worst headache of your life, patients dont typically know they have an anyeurism
22
Q
3 stroke assessment signs
A
- facial droop
- motor weakness
- language difficulties
Face: facial droop, uneven smile
Arms: numbness, weakness
Speech: slurred, difficulty speaking or understanding
Time: call 911 and get to hospital immediately
23
Q
stroke symptoms
A
- left
- slow, cautious
- depressed
- anxious
- slow speech
- right paralysis
- right
- impulsive
- denies problems
- talks fast
- safety risks
- left paralysis
- left side neflect
24
Q
symptoms of stroke
A
- motor: contralateral flaccidit then spasticity within 48 hours, hemiplegia, hemiparesis
- communication: aphasia (receptive or expressive), nonfluent speech requires lots of effort, fluent speech is meaningless, non sensical, dysarthria muscles for speech are weak, dysphasia receptive, expressive global
- affect: cant control emotions
- intellect: left: cautious, right impulsive
- spatial perceptual: more problems in right sided strokes, homonymous hemianopsia (only see 1/2 vision), agnosia (inability to recognize familiar objects)
- elimination: urinary problems are temporary, constipation is long term
25
stroke diagnostic studies
- CT is most important, distinguishes stroke and ischemic vs hemorrhage
- CT angiography
- MRI
- transcranial doppler, bleeds
- LICOX monitoring, can tell if stroke is progressing
26
stroke treatment
- prevention: control HTN, diabetes, heart problems, no smoking, limit alcohol intake, if having TIAs look for cause
- Antiplatelet drugs for TIAs: ASA, plavix, warfarin (prevent clots but don't dissolve)
- surgery: carotid endarterectomy, transluminal angioplasty, stenting, EC-IC bypass
27
treatment by type of strokes
- ischemic: time of onset is most important, give tPA within 3-4.5 hours of onset (Gold standard), ABCs, no seizure prophylaxis, no heparin but may give ASA, keep BP slightly high, dont overhydrate, keep fever free
- hemorrhagic: no anticoagulants or platelet inhibitors, give seizure prophylaxis, prevent HTN keep BP
28
acute stroke interventions
- respiratory: high risk of atelectasis & pneumonia (esp aspiration pneumonia), may need an artificial airway, swallowing issues, loss of gag reflex
- Neuro: assess baseline, post 24 hours, 7-10 days and 3 months; use HTN stroke scale, mental status, pupil changes, extremity movement/strength, Vital signs
- cardiovascular: oftentimes have limited reserves, maintain F&E balance, prevent HTN, prevent DVTs
- musculoskeletal: prevent joint contractures and muscle atrophy, ROM (active or passive), positioning
- skin: prone to breakfown due to loss of sensation, decreased circulation, pressure relief, skin hygiene
- GI: prevent constipation, stool softeners
- Urinary: may have some incontinence, usually does resolve, bladder training, watch for restlessness
- nutrition: ST to assess swallowing ability, keep upright, assess a gag reflex, pureed diet is too smooth or bland, use thick-it, chin tuck and double swallow, watch for pocketing
- communication: ask yes or no questions, may not be able to read words, give plenty of time to respond, picture boards
- sensory-perceptual: homonymous hemianopsia, eye patches for diplopia, neglect syndrome, high risk for injury
- coping: clearly communicate, repeat teaching often, help with arranging follow up care, depression can be common
- PT
- OT
- ST
29
Home interventions stroke
- musculoskeletal: if muscles are still flacid prognosis is poor, balance training, use of assistive devices
- nutrition: may need PEG, encourage self feeding
- bowels: prevent constipation, bowel retraining
- bladder: regular voiding schedule q 2 hours,
- sensory/perceptual: right - impulse, tend to deny problems, risk for injury, one sided neglect; left - slower to organize/perform tasks, fearful, anxious
- affect: left - mood swings; may be unable to conrol emotions, distraction may help, do not punish
- coping: many losses, often have depression,
30
olfactory nerve assessment (CN I)
- test both nostrils are patent then close one nostril and have them do a smell test
- disturbance of smell may be associated with tumor or skull fractures
31
optic nerve assessment (CN II)
- assess visual fields and acuity
- have pt look at their nose: visual field defect may mean lesions of optic nerve, optic chiasm or tract,
- test visual acuity by asking the pt to read a snellen chart
32
Ocluomotor, trochlear and abducens nerve assessment (CN III, IV, and VI)
- always tested together, help test eye movement
- test 6 carinal gaze test with pen light
- this test can find a disconjugate gaze (not moving together), nystagmus (rapid jurking movements)
- test pupilary restriction and accomodation
- PERRLA
- look for ptosis (drooping eyelid) and eye muscle weakness
33
Trigeminal nerve assessment (CN V)
- test light touch and pinprick on face with eyes closed
| - clench teeth and palpate masseter muscles
34
Facila nerve assessment (CN VII)
- raise eyebrows, close eyes tightly, purse lips, smile, frown
- taste of salt and sugar on front 2/3 of tongue
35
vestibulocochlear (acoustic) nerve assessment (CN VII)
- close eyes and whisper very quiet in ear
36
glossopharyngeal and vagus nerve assessment (CN IX and X)
- test gag refex
- test swallowing
- say "ah"
- cough for vagus nerve assessment
37
accessory nerve assessment (CN XI)
- shrug shoulders and turn head with resistence
38
hypoglossal nerve assessment (CN XII)
- protrude tongue
| - move tongue around and against resistence of a tongue blade
39
motor system neuro assessment
- ROM tests
- Strength tests
- hypotonia: flaccidity
- hypertonia: spacicity
- myoclonus: spasm of muscles
- athetosis: slow, writhing, involuntary movements of extremities
- chorea: involuntary, purposeless, rapid motions
- dystonia: impairment of muscle tone
- cerebellar function: balance and coordiation, observe pt stature and gait, finger to nose test
40
romberg test
- tests proprioception
- stand with feet together then close eyes
- if falls with closed eyes means vestibulocochlear dysfunction or diease in posterior columns of spinal cord
41
sensory tests
- two point discrimination test
- graphesthesia: ability to feel writing on skin
- stereognosis: ability to preceive the form and nature of objects
42
neuro assessment abnormalities
- speech: aphasia/dyspahsia (loss of or impaired language faculty, comprehension, expression or both); dysarthria (lack of coordination for speech)
- eyes: anisocoria (inequal pupil size), diplopia (double vision), homonymous hemianopsia (loss of vision in one side of visual field)
- cranial nerves: dysphagia (diff swallowing), ophthalmoplegia (paralysis of eye muscles), papilledema (swelling of optic nerve head)
- motor: apraxia (inability to perform learned movements despite having desire to do so), ataxia (lack of coord of movement), dyskinesia (impairment of voluntary movement), hemiplegia (paralysis of one side), nystagmus (jerking or bobbing of eyes as they track moving objects)
- sensory: analgesia (loss of pain), anesthesia (absence of sensation), paresthesia (alteration in sensation), astereognosis (inability to recognizze form of object by touch)
43
headaches
- common source of pain
- primary: tension, migraine, cluster
- secondary: symptom of other primary disease process
44
tension headache
- pain is bilateral
- constant squeezing or tight band sensation
- mild to moderate intensity
- unaffected by activity
- no prodrome, no n/v
- cycles for many years
- can lasdt 30 minutes - 7 days
- may have photophobia and/or phonphobia (sounds phobia)
- tx: nonopioid analgesic, sedatives, muscle relaxants, tranquilizers, codeine
- fiorinal (habit forming)
45
migraine headache
- unilateral, may switch sides
- throbbing, with pulse
- periodic cycles of several months to years
- 4-72 hours
- gets better with sleep
- symptoms: n/v, sweating, irritability, sensitivity to light and sound, family history
- tx: triptans (cause vasoconstriction), preventative drugs (topamax, depakote, take months to work), dark quiet area, sleep
46
cluster headaches
- unilateral, radiating up or down from one eye
- severe, bone crushing pain
- months or years between attacks
- attacks occur in clusters over a period of 1-12 weeks, last 5 min - 3 hours
- occur at night and wake pt from sleep
- symptoms: flushing, ptosis, rhinitis, pallor, lacrimation
- tx: 100% oxygen, triptans sometimes
47
headache interventions
- daily exercise
- relaxation techniques
- quiet, dimly lit environment
- massage
- mosit hot packs
- dietary counseling: wine can trigger migraines
- medications
48
multiple sclerosis
- chronic, progressive, degenerative disorder of the CNS
- characterized by segmental demyelination of nerve fibers of the brain and spinal cord
- onset between 20-50 years
- women are affected 2-3 times more than men
- more prevalant in temperate climates 45-65 degrees
- myelination is damaged but nerve impulses are still transmitted
- myelin can regenerate and pt goes into remission
- onset is often vague and gradual over months or years
49
MS clinical manifestations
- motor, sensory, cerebellar and emotional problems
- fatigue, depression, visual issues,
- speech issues
- constipation, bladder issues
- looks a lot like lyme disease but does not respond to antibiotics
- average life expectancy after onset of symptoms is more than 25 years
- death occurs as a result of infectious complications of immobility or because of an unrelated disease
50
MS diagnostic studies
- no definitive diagnostic test
- based primarily on history, clinical manifestations, results of certain diagnostic tests
- MRI of brain and spinal cord may show presence of plaques, inflammation, atrophy, and tissue breakdown and destruction
- diagnosis: 2 inflammatory demyelinating lesions in at least 2 different locations within the CNS, damage or an attack occuring at different times, all other possible diagnoses ruled out
51
MS drug therapy
- collaborative care, provide symptomatic relief
- immunosupressive drug therapy: dlow progression of disease, immunosuppressants, immunomodulators (interferon - flud symptoms, sun sensitivity), ACTH
- corticosteroids: methylprednisolone, prednisone, can treat acute exacerbations by reducing edema and acute inflammation at the site of demyelination
- muscle relaxants for spacicity
- CNS stimulants to treat fatigue (cylert, ritalin, probigil)
- anticholinergics for bladder symptoms
- tricyclic antidepressants and antiseizure drugs for chronic pain
52
MS collaborate care
- PT: relieve spasticity, improve coordination, water therapy for exercise
- manage fatigue
- look at psychosocial wellbeing
- decrease factors that precipitate stress: heat, stress
- teach: minimize caffeine, nutritions well balanced meals, self catheterization, intake of fiber, lifestyle adjustments
53
parkinson's disease
- chronic progressive neurodegenerative disorder
- diagnosis increases with age
- more common in men
- not quite known what causes it: genetic component, can be related to encephalitis, drug induced, etc
- lack of dopamine in the brain: disrupts dopamine-ACTH balance in basal ganglia
54
PD clinical manifestations
- onset is gradual
- classic triad of PD: tremor, rigidity, bradykinesia
- later stages: shiffling, propulsive gait with arms flexed, loss of postural reflexes, slight speech changes
- tremor: more prominant at rest and aggrivated by emotional stress or increased concentration, described as pill rolling becayse thumb and forefinger sppear to move in roatry fashion
- Rigidity: increased resistence to passive motion when limbs are moved through ROM, jerky, caused by sustainted muscle contraction and consequently elicits soreness, feeling or tired and achy, pain in head, upper body, spine
- Bardykinesia: shuffeling gait, loss of autonomic movements - blinking, swinging of arms, swallowing saliva, self expression with facial movements
- nonmotor symptoms: depression, anxiety, fatigue, pain, constipation, sleep problems, short term memory loss
55
PD complications
- cx increase as disease progresses
- weakness
- akinesia - total immobility
- neurologic problems
- neuropsychiatric problems
- demential in 70% of PD pts
- dysphagia may result in malnutrtion and aspiration
- orthostatic hypotension
56
PD diagnostic tests
- based solely on history and clinical features
| - firm diagnosis if 2 of 3: tremor, rigidity, bradykinesia
57
drug therapy for PD
- aimed to relieve symptoms
- Anti PD drugs: enhance release of dopamine or antagonize effects of overactive cholinergic neurons
- Levodopa-carbidopa (sinemet): first drug of choice, precursos of domapine and crosses BBB, carbidopa inhibitis an enzyme that breaks down levodopa before it reaches the brain, sinemet can start to wear off over time and may need additional med therapy
- anticholinerics: decrease activity of ACTH
- antihistamines with anticholinergic or beta blockers: manage tremors
- antiviral agent: amantadine
- excessive dopaminergic drugs can lead to paradoxic intoxication: aggrivation of PD symptoms
- within 3-5 years of tx pts experience episodes of hypomobility
58
collaborative care for PD
- surgery: ablation, deep brain stimulation, transplant of fetal neural tissue
- nutrition: malnutrtion and constipation can be serious side effects, need food that is easy to chew and swallow, adequate roughage in diet, cut food into bite size pieces, several small meals to prevent fatigue, give ample time to eat to avoid frusteration, levodopa can be impaired by vitamin b6 ingestion and protein
59
PD nursing care
- maintain independence in ADLs
- emphasize abilities and not disabilities
- simple clothing
- fall prevention
- exercise assistance with PT
- improve gait: consciously think about stepping, drop rice to step over, life toes with each step
60
seizure disorders
- paroxysmal, uncontrolled electrical discharge of neurons in brain, interrupting normal fxn
- may accompany other disorders or occur spontaneously without apparent cause
- metabolic disturbances associated with seizures: acidosis, electrolyte imbalance, hypoglycemia, hypoxemia, alcohol or barbituate withdrawl, dehydration or water intoxication
- extracranial disorders associated with seizures: HTN, systemic lupus, DM, septicemia
61
Epilepsy
- spontaneously recurring seizures caused by unerlying chornic condition
- 50: stroke, brain tumor
62
epilepsy clinical manifestations
- generalized: involve both sides of brain, pt looses consciousness for seconds-minutes, tonic clonic, absence seizures
- focal: begin in specic area of brain, produce s/s of related to that area of the brain affected, simple, complex
63
phases of a seizure
- prodronmal phase
- aural phase
- ictal phase
- postictal
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tonic clonic seizures
- most common generalized seizure
- "grand mal"
- loosing consciousnes, falling to ground, stiffening of body (tonic) for 10-20 seconds and subsequent jerking of extremeties (clonic) for 30-40 seconds
- cyanosis, excessive salvation, tongue or cheek biting, incontinence
- postictal: muscle soreness, tired, sleep for several hours, may last several hour or days after
65
typical absence seizures
- generalized seizure, petit mal
- occurs only in children and rarely continues beyond adolescence
- brief staring spell that lasts a few seconds
- if untreated may occur up to 100 times a day
- hyperventilation and flashing lights can precipitate it
66
atypical absence seizures
- generalized seizure
- staring spell accompanied by other s/s like peculiar behavior before the seizure, confusion after the seizure
- longer lasting that typical absence seizure
67
myoclonic seizure
- sudden, excessive jerk of body or extremities
- brief and may occur in clusters
- may throw someone down to the ground
68
atonic seizure
- involves tonic episode or paroxysmal loss of muscle tone
- consciousness occurs right after person hits the ground
- normal activity can be resumed immediately
69
tonic seizures
- sudden onset of maintained increased tone with the extensor muscles
- patients can fall
70
clonic seizurs
- begin with LOC and sudden loss of muscle tone, followed by limb jerking that may or may not be symmetric
71
simple focal seizures
- person remains conscious
- experiences unusual feelings or sensations that can take many forms
- sudden unexplained feelings of joy, anger, sadness, nausea
- may hear, see , taste, smell things that are not real
72
complex focal seizures
- person has a change or loss of consciousness
- produces a dreamlike experience
- display strange behavior: lip smacking, repretive movements
- usually lasts a few seconds
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psychogenic seizures
- seizures that are psychiatric in origin
- video EEG required for diagnosis
- history of emotional abuse, physical neglect, specific trauamatic episode
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status epilepticus
- state of continuois seizure activity or a condition in which seizures recur in rapid succession without return to consciousness between seizures
- most serious complciatino of epilepsy
- neurologic emergency
- causes the brain to use more energy thatn is supplied, neurons become exhausted and cease to fxn, permanent brain damage can result
75
tonic clonic status epilepticus
- most dangerous complication of epilepsy
- can cause ventilatory insufficiency, hypoxemia, cardiac dysrhythmias, hyperthermia, systemic acidosis
- can be fatal
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epilepsy diagnostic procedures
- health history
- EEG
- CBC
- serum chemistries
- liver and kidney fxn tests
- CT or MRI
- UA to rule out metabolic disorders
- cerebral angiography
77
care of seizure disorders
- self limiting and most do not require ED
- immediate care if: status epilepticus, significant bodily harm, first time seizures
- antiseizure drugs: work in about 70% of pts
- drugs work by stabilizing nerve cell membranes and preventing spread of the epileptic discharge
- many drugs have a long half life and can be given 1-2 x day
- common side effects: diplopia, drowsiness, ataxia, mental slowing
DRUGS
- generalized tonic clonic and focal seizurs: phenytoin/dilantin, carbamazepine/tegretol, phenobarbital/luminal, divalproex/depakote, primidine/mysoline
- absence or myoclonic seizures: ethosuzimide/zarontin, divalproex/depakote, clonazepam/klonopin
- broad spectrum drugs for multiplc seizure types: gabapentin/neurontin, lamotrigine/lamictal, topiramate/topamax, tiagabine/gabitril, levetiracetam/keppra, zonisamide/zonegran
- pregabalin (lyrica): used as an add on for control of focal seizures that are not successfully managed with a single medication
- status epilepticue: intially, rapid acting IV lorazepam (ativan) or diazepam (valium), followed by long acting drugs
78
seizure collaborative care
- testing for toxicity: nystagmus, hand and gait coordiantion, cognitive fxn, general alertness
- gerontologic concerns: new onset seizures, carefully find out difference between normal aging and effects of drug therapy, phenytoin may cause liver failure; phenobarbital, tegretol, mysoline negatively effect cognitive fxn
- drug interations with: carbamazepine, phenytoin, phenobarbital
- fewer effects on cognitive fxns: gabapentin, lamotrigine, oxcarbazepine, levetiracetam
- surgery to remove epileptic focus of brain
- anterior love resection
79
myasthenia gravis
- autoimmune disease of neuromuscular jxn characterized by fluctuating weakness of certain skeletal muscle groups
- caused by autoimmune process in which antibodies attack ACh receptors, resulting in decreased number of ACh receptor sites and the neuromuscular jxn, this prevents ACh molexules from attaching and stimulating muscle contractions
80
MG assessment
- fluctuating muscle weakness of skeletal muscle
- most often involves muscles that move eyelids, chewing, swallowing, speaking and breathing
- stongest in the morning then become exhausted after activity, rest helps
81
MG physical exam
- progressive muscle weakness without atrophy
- no change in senation or reflexes
- fatigue
- speech difficulties
- ocular palsies
- ptosis
- diplopia
- respiratory distress
- cough, gag reflexes
82
MG complications
- myasthenic crisis: tx with neostigmine, acute exacerbaton of muscle weakness triggered by infection, surgery, emotional distress, drug overdose, inadequare drugs
- Cholinerigic ciris: tx with atropine, excess Ach causes overstimulation of muscles
- respiratory insufficiency
- aspiration
83
MG diagnostic tests
- EMG and tensilon test
- used to diagnose MG or distinguish between myasthenic or cholinergic crisis
- if they fatigue and dont get stronger again after rest they dont have MG
- increased weakness = cholinergic crisis
84
MG tx
- anticholinesterase drugs - mestinon or pyridostigmine
- alternate day corticosteroids - prednisone
- immunosuppressants - cyclosporine, imuran
- avoid many classes of drugs
- thymectomy
- plasmapheresis weekly
- immunoglobulin G
85
MG nursing care
- distinguish between myasthenic crisis and cholinergic crisis
- watch for s/s of resp insufficiency
- semisolid foods
- schedule drugs so peak action is at mealtimes
- perform physically demanding activity early in AM
86
Amyotrophic Lateral Sclerosis (ALS)
- Lou Gehrig's disease
- rare, progressive disorder with loss of motor neurons
- death from resp failure within 2-6 years
- symtoms: weakness of upper extrems, dysarthria, dysphagia
- no tx
- remains cognitively intact while wasting away
87
huntington's diease (HD)
- genetic disease with deficiency of ach and GABA
- s/s: chorea, worsening gait, risk for aspiration/malnutrition, cognitive deterioration, loss of speech
- need 4-5k calories a day
- death within 10-20 years, no cure
- xenaxine for chorea, haldol, valium, dopamine depleating agents
- chorea: abnormal and excessive involuntary movements
88
Dementia
- syndrome characterized by dysfunction or loss of: memory, orientation, attention, language, judgment, reasoning
- > 60 yrs
- cannot truly be fixed
- depression is a major component
- other characteristics: personality changes, behavioral problems like agitation, delusions, hallucination
- often diagnossed when 2 or more brain functions are significantly impaired
- 60% with dementia have AD
89
cognitive problems
- most common in adults
- dementia
- delirium: short lasting, no residual effects
- depression
90
alzheimer's disease
- cannot be prevented, cured, or slowed
- slightly higher in AA and hispanics
- women more likely to develop
- chronic, progressive, degenerative
- causes: genetics, inflammation, viruses, age > 65, diabetes, smoking, depression
91
AD patho
- beta amyloid plaques and neurofibtrillary tangles
- loss of connections between neurons
- cell death and brain atrophy
- decrease in ach
92
AD clinical manifestations
- progress varies from person to person and ranges from 4-8 years
- some people live for 20 years
- dysphasia
- apraxia - cannot do regular movements
- visual agnosia
- dysgraphia
- some long term memory loss
- wandering
93
AD memory loss s/s
- puts things in inappropriate places
- doest remember knowing someone
- loses language skills and socially withdrawls
- loses sense of time doesnt know the day
- serious recent meory loss cant learn new info
- easily disoriented or lost in familiar places for hours
- has little or no awareness of cognitive problems
94
mild, moderate and severe dementia
- mild: foregetfulness beyond normal, short term memory problems, problems with new learning, problems recognizing what numbers mean, decreased judgement, geographic disorientation
- moderate: cant recognize close family and friends, agitation, wandering, lost, loss of remote memory, confusion, forget how to do simple tasks, aphasia, insomnia, hallucinations, behavior problems
- severe: little memory, unable to process new info, cant understand words, difficulty eating, swallowing, makes repetive sounds and words, unable to perform self care activities, immobility, incontinence
95
AD prevention
- recognize the disease early
- diet changes: more colorful fruits, veggies, soy, more folate, b12, C, E
- exercise
- NSAIDs
96
AD diagnostic tests
- only autopsy can really diagnose
- labs: CBC, CMP, thyroid, liver fxn, drug and alcohol screens, syphilis
- CT
- PET
- MRI
- neuropsych testing
97
AD tx
- cholinesterase inhibitors: aricept, exelon, razadyne = slow progression, best given early in disease
- namenda (memantine): protect against glutinate which causes cell damage
- antidepressants: may improve cognition, may help with sleep
- antipsychotics: can be dangerous, avoid at all costs, can expedite death
98
AD nursing care
- provide structure and consistency, routines, place for everything, clocks, calendars
- prevent overstimulation: ensure undisturbed sleep, tv off most of the time - can cause overstim
- prevent/control agitation: redirect, distract, reassure, limit choices, give simple directions
- what NOT to do: threaten, confront, explain, take offense, restrain
- prevent injury: 24 hr supervision, medic alert bracelet, alarms on doors and beds, boundaries, fall prevention
- sundowner's syndrome: most confused at night, limit naps, open windows, turn on lights, activity during the day
99
types of dimentia
- AD: most common, plaques and tangles, diagnosis at autopsy only
- vascular: second leading cause of dementia; develops quickly; associated with CVA/TIAs; depression is common
- dementia with lewy bodies: decline similar to AD with addition of sleep disturbances, visual hallucinations, parkinsonian like movements, dysphagia
- frontotemporal lobar degeneration: ocalized atrophy of frontal and temporal loves, behavior and personality changes, promary progressive aphasia
100
normal pressur hydrocephalus (other dementia)
- rate but reversible
- obstruciton in flow of CSF, enlarged ventricles but no rise in ICP
- associated with traumatic head injury, meningitis, encephalitis
- triad of symptoms: gait disturbance, urinary incontinence, cognitive dysfunction
- treat the problem then this gets better
101
creutzfeldt jakob disease (other dimentia)
- rare and fatal brain disorider
- casued by prion protein: mad cow disease, risk of contracting CJD is extremely rate
- supportive tx
102
delirium
- impairment such as confusion, hallucination, delusion is not normal aspect of aging, may represent an active disease process
- change in LOC and cognition that develop over a short period of time
- acute onset and reversible cause
```
Dementia, dehydration
Electrolyte imbalances, emotional stress
Lung, liver, heart kidney, brain
Infection, intensive care unit
Rx drugs
Injury, immobility
Untreated pain, unfamiliar environmnet
Metabolic disorders
```
103
dementia vs delirium
- insidious onset vs rapid onset
- symptoms progress vs lucid intervals
- duration of months-years vs hours to month
nursing care
Dementia: careful assessment MMSE, CT/MRI to look for vascular changes, similar care for AD
Delirium: recognition of high risk pts, careful assessment CAM tool, reorient frequently, calm/safe enviro, drugs only for severe anxiety
104
depression
- manifestations of depression and dementia are often confused
- disorders often occur together
- memory and functional impairment can be significant in severe deprssion
- definition: change in mood which lasts at least 2 weeks and includes sadness, negativity, loss of interest, pleasure or decline in function
105
dementia assessment tools
- mini-cog: involves drawing clocks and remembering sets of words, AD assessment
- Geriatric depression scale
- confusion assesssment method
- mini mental state exam: screens for cognitive loss
