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441 > Intracranial Regulation > Flashcards

Intracranial Regulation Flashcards

1
Q

High cervical nerve injuries (C1-C4)

***the higher the injury on the spinal cord, the more dysfunction can occur

A

Most severe of the spinal cord injury levels
Paralysis in arms, hands, trunk, and legs
May not be able to breathe on own, cough, or control bowel/bladder movements
Speech may be impaired or reduced
Tetraplegia or quadriplegia of all four limbs are affected
Complete assistance with ADLs such as eating, dressing, bathing, and getting in and out of bed
May be able to use powered wheelchairs to move on their own
Will not be able to drive a car
Requires 24/7 personal care

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2
Q

Low cervical nerves (C5-C8)

A

Corresponding nerves control arms and hands

May be able to breathe on own and speak normally

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3
Q

C5 injury

A

Can raise arms and bend elbows
Likely to have some or total paralysis of wrists, hands, trunk, and legs
Can speak and use diaphragm, but breathing will be weakened
Will need assistance with most ADLs
Can move independently in powered wheelchair

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4
Q

C6 injury

A

Nerves affect wrist extension
Paralysis in hands, trunk, and legs
Should be able to bend wrists back
Can speak and use diaphragm but breathing is weakened
Can move in and out of wheelchair and bed with assistive equipment
May be able to drive adapted vehicle
Little to no control of bladder/bowels, but may be able to manage on own with special equipment

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5
Q

C7 injury

A

Nerves control elbow extension and some finger extension
Most can straighten arm and have normal shoulder movement
Can do most ADLs, but may need assistance with more difficult tasks
May be able to drive an adapted vehicle
Little to no control of bladder/bowels but may be able to manage on own with special equipment

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6
Q

C8 injury

A

Nerves control some hand movement
Should be able to grasp and release objects
Can do most ADLs but may need assistance with more difficult tasks
May be able to drive an adapted vehicle
Little to no control of bladder/bowels but may be able to manage with special equipment

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7
Q

Thoracic nerves (T1-T-5)

Thoracic vertebrae are located in the mid-back

A

Corresponding nerves affect muscles, upper chest, mid-back, and abdominal muscles
Arm and hand function is usually normal
Injuries usually affect the trunk and legs (paraplegia)
Most likely use a manual wheelchair
Can learn to drive a modified car
Can stand in a standing frame, while other may walk with braces

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8
Q

Thoracic nerves (T6-T12)

A

Nerves affect muscles of the trunk (abdominal and back muscles) depending on the level of injury
Usually results in paraplegia
Normal upper body movement
Fair to good ability to control and balance trunk while in the seated position
Should be able to cough productively (if abdominal muscles are intact)
Little to no control of bladder/bowels but can manage on own with special equipment
Most likely use a manual wheelchair
Can learn to drive a modified car
Some can stand in a standing frame, others may walk with braces

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9
Q

Lumbar nerves (L1-L5)

A

Injuries tend to result in loss of function in hips and legs
Little to no control of bladder/bowels but can manage with special equipment
Depending on strength in legs, may need wheelchair and may also walk with braces

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10
Q

Sacral nerves (S1-S5)

A

Injuries generally result in some loss of function of the hips and legs
Little to no control of bladder/bowels but can manage with special equipment
Most likely will be able to walk

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11
Q

Testing the olfactory nerve (Cranial Nerve I)

A

Have the PT close their eyes and offer something familiar and pleasant to smell and identify

(e.g., orange/lemon peel, coffee, vanilla)

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12
Q

Testing the optic nerve (Cranial Nerve II)

A

Test visual acuity using as Snellen chart, 20 feet away, with and without visual aids
Use Ishihara color test palate to assess for color blindness
Visual field- look at you while you wiggle one finger in each of the four quadrants, wiggle both to ensure patient can recognize this
Visual reflexes- PERRLA
Use fundoscopy in both eyes

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13
Q

Testing the oculomotor nerve (Cranial Nerve III), the trochlear nerve (Cranial Nerve IV), and abducent nerve (Cranial Nerve VI)

A

6 cardinal fields of gaze- look for nystagmus (shaking of eye)
Ask if they experience any blurry vision and when it’s worse

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14
Q

Testing the trigeminal nerve (Cranial Nerve V)

A

Look at sensory and motor supply to the muscles of mastication: ophthalmic (on the forehead), maxillary (on the cheek), and mandibular (around the jawline)
Test corneal reflex by going to put a cotton ball in the eye lightly which should cause the patient to shut their eyes
Clench teeth and feel the masseter and temporalis muscles
Open mouth against resistance
Jaw jerk- place left index finger on chin, strike finger with tendon hammer which should cause slight protrusion of the jaw

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15
Q

Testing the facial nerve (Cranial Nerve VII)

A 
Raise eyebrows
Close eyes, keep them closed against resistance
Puff cheeks
Smile
Frown
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16
Q

Testing the vestibulocochlear nerve (Cranial Nerve VIII)

A

Can be used to differentiate conductive and sensory-neural hearing loss using the Rinne and Weber tests

Rinne under the penny or pinna at the mastoid process (bone conduction) then next to their ear (air conduction). Air conduction should be louder than bone conduction (AC>BC)

Weber it’s right or left. Place tuning fork at center of forehead. Sound should be heard equally in both ears. If louder in right= sensors-neural hearing loss in left ear and vice versa

Whisper test- occlude opposite ear from the side you whisper on

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17
Q

Testing the glossopharyngeal nerve (Cranial Nerve IX)

A

Gag reflex

Touch arches of the pharynx

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18
Q

Testing the vagus nerve (Cranial Nerve X)

A

Speech gives good indication to the efficacy of muscles
Say “ahh” and look at the uvula which should rise and stay midline
Assess ability to swallow

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19
Q

Testing the accessory nerve (Cranial Nerve XI)

A

Turn head against resistance to assess sternocleidomastoid muscles

Shrug shoulders against resistance to assess trapezius muscles

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20
Q

Testing the hypoglossal nerve (Cranial Nerve XII)

A

Stick tongue out
Wiggle/ move tongue side to side
Observe for signs of wasting or sucks twitching

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21
Q

Assessing deep tendon reflexes (DTRs)

A

Locations: bicep, tricep, patellar, Achilles, and brachioradialis

Use a reflex hammer

Evaluates lower motor neurons/fibers at specific levels in the body. Ex: brachioradialis assesses spinal nerve root C5 to C6; triceps assess C7 to C8; biceps assess C5-C6; patellar assess L2-L4; Achilles assess L5-S2

Used with preeclampsia patients, hyperactive patients, and magnesium sulfate infusions

4+= hyperactive (clonus) 
3+= brisker than normal; hyperreflexive 
2+= normal
1+= diminished, hyporeflexive 
0= absent

Swing hammer briskly and remove
Have the patient flex that muscle to find the tendon (feels cordlike)

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22
Q

Central nervous system

A

Brain

Spinal cord

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23
Q

Peripheral nervous system

A

Motor: somatic; autonomic (sympathetic, parasympathetic)

Sensory

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24
Q

Afferent pathway

A

Toward cell body from other neurons

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25
Q

Efferent pathway

A

From cell body to other cells through axon

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26
Q

Myelin sheath

A

Lipid covering “white matter”

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27
Q

Non-mylenated

A

Gray matter

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28
Q

Neurotransmitters

A

Stored in presynaptic side of neuron

Either excite or inhibit impulse through neuron

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29
Q

Synapse

A

Space between neuron

Neuron to neuron or neuron to muscle

30
Q

Strength of impulse

A

Depends on nearness to cell body

Inhibition by another neuron, inadequate supply of transmitter substance, extra cellular fluid exchange

Hypoxia

Acidosis- depresses

Alkalosis- excites

31
Q

Neuroglial cells

A

Protection
Structure
Nutrition

32
Q

Meninges

A

Protective covering
Dura- outside later
Arachnoid- middle layer
Pia mater- inside later

33
Q

Cerebrum

A

Right and left hemisphere joined by corpus callosm

Lateral ventricles

Basal ganglia- mobility

Motor cortex- voluntary movement; pyramidial tracts start in motor cortex and cross in medulla

Diencephalon- thalmus: hypothalamus (ANS control) and epithalamus (pineal gland)

Hypophysis- pituitary gland

34
Q

Cerebellum

A

Message to joints, muscles, tendons

Equilibrium

Voluntary movement

Sequential movement

Ipsilateral control

35
Q

Brainstem

A

Medulla- slow HR and RR (CN IX, X, XI, XII, and parts of VII and VIII)

Pons- HR acceleration and vasoconstriction (respiratory pattern and rate; CN V, VI, VII, VIII)

Midbrain- CN III and IV

RAS- awareness and alertness

36
Q

Brain

A

Circulation from carotid and vertebral arteries

BBB- cerebral capillaries joined tightly together; allow small molecules: oxygen, glucose, CO2, etoh, anesthesia, H2O

CSF- produced in choriod plexus; surrounds and cushions brain and spinal column

37
Q

ANS

A

Sympathetic stimulates fight or flight; inhibits functions not needed

Parasympathetic slows body functions

38
Q

PNS

A

Dermatomes- sensory input from spinal nerves to area of skin

Sensory receptors- pain, temp, touch, vibration, pressure, visceral, proprioception

Reflex

39
Q

Level of consciousness

A

Full- A&O x3
Confusion- unable to think rapidly and clearly
Disoriented- alert but missing an orientation
Obtunded- lethargic; responsive to verbal/tactile stimuli but drifts back to sleep
Stupor- unresponsive; aroused by repeated or painful stimuli; will grab at source of pain
Semicomatose- no spontaneous movement; pain result in stirring and withdrawal but no arousal
Coma- unareousable; no withdrawal from pain; nonpurposeful movement
Deep coma- unarousable to all stimuli; no brainstem reflexes (corneal, pharyngeal, tendon)

40
Q

Assess memory and attention

A

Remote: birth date, city of birth, mothers maiden name

Recall (recent): check accuracy of medical history

Immediate: repeat 3 words and again in 5 minutes

Language: follows directions, copy words or symbols

41
Q

Sensory

A

Pain (dull, sharp)

Light touch

42
Q

Motor

A

Hand grasps
Strength against resistance
Pronator drift

43
Q

Cerebellar

A 
Coordination
Heel over skin
Alternate palm on thigh
Finger to nose
Romberg- stand with eyes closed
44
Q

Glasgow coma scale

A

Eye opening (spontaneous-4, to command-3, to pain-2, none-1)

Verbal response (oriented-5, confused-4, inappropriate-3, incomprehensible-2, none-1)

Motor response (obeys commands-6, localized pain-5, withdrawals from pain-4, abnormal flexion-3, extension-2, none-1)

45
Q

Decorticate posturing

A

Internal rotation of arms and plantar flexion of legs (corticospinal)

46
Q

Decerebrate posturing

A

Extension arms and legs; rigidity (brainstem)

47
Q

Diagnostics

A

Labs- infection, electrolytes

X-ray to rule out trauma

CT, CTA

MRI, MRA

EMG- assess nerve conduction

EEG- electrical conduction of brain; 24 hour video monitor

48
Q

Lumbar puncture

A

Side lying or sitting
Curl to open spaces

Educate patient

Sedation for non-compliant

49
Q

Cerebral palsy

A

Permanent disorder- motor, sensation, perception, communication, cognition, behavior, seizures

Classification: spastic (lots of muscle spasms) dyskinetic (disjointed movement), ataxic (tremors), mixed- very common

Diagnosis: MRI (newborns with head injury or subdermal bleed), failure to meet milestones, persistent primitive reflexes (babinski, rooting, startle, etc.)

CNS disorder of the cerebellum caused by congenital tissue, problem with fetal development, birth trauma, maternal hypoxia

50
Q

Cerebral palsy management

A

Multidisciplinary planning- PT, OT, speech therapy, special education, rehab

Contracture- bracing, surgery- tendon release

Spasticity- meds, Botox/phenol, baclofen pump

Seizure- anti epileptics

Nutrition- feeding difficulties- may need G tube but encourage them to eat and feed via G tube at night to make up for other nutrients needed.

Functioning

Baclofen is first choice to prevent sleepiness or neuro changes. Dantrolene can be used to prevent spasms. Botox to help the muscle relax so they have better control over the muscle. Phenol injections into hypertrophied muscles to burn off some muscle tissue; less tissue = less spasms and better ability to control the muscle. A baclofen pump may be inserted into the lower spinal cord area where small amounts are released to help with leg control but only done if trial proves it will be effective for them.

51
Q

Parkinson’s disease

A

Basal ganglia- group of neurons in cerebrum

Dopamine inhibits in basal ganglia

Acetylcholine (Ach) excites in basal ganglia

Together coordinate fine movement

Degeneration of substantia nigra

Loss of sympathetic response (orthostatic hypotension)

CNS defect of dopamine production and the basal ganglia affecting neuromuscular control

Have Ach and not dopamine, you have massive amounts of muscle tone but not the ability to control that tone

Degeneration of substantia nigra that no longer produces dopamine in the brain; there is more excitation and less control over fine movements; less dopamine also has less of a sympathetic nervous system response for the heart and vascular system and orthostatic hypotension is very common

52
Q

Parkinson’s symptoms

A

Four cardinal symptoms: tremor, muscle rigidity, bradykinesia, postural instability

Autonomic- hypotension, perspiration, flushing, urine, constipation

Speech- dysarthria, hypophonia, echolalia

Psychosocial- labile, depression, paranoid, sleep disturbance

Diagnosis- H&P, CSF, MRI

Other S/S: stooped posture, flexed elbows and wrists, trembling of extremities, masked facial expression, forward tilt of trunk, reduced arm swinging, slightly flexed hips and knees, shuffling/short-stepped gait

CSF may show decreased dopamine. MRI to rule out tumor.

Tremor usually begins in upper extremities and increases with stress. Ball or pin between fingers with rubbing. May have resistance to passive ROM; assess ability to relax a muscle group; often CN VII is impaired; may have difficulty chewing or swallowing and some uncontrollable drooling

53
Q

Parkinson’s drug treatment

A

Dopamine agonists- apomorphine, pramipexole, ropinirole: risk for hypotension, hallucinations, sleepiness; most effective in first 3-5 years

Levodopa-carbidopa: empty stomach; most commonly used; good for improving motor control. Must be taken on empty stomach to increase absorption and cross the blood-brain barrier

Catechol O-methyltransferases inhibitors- entacapone (COMT inhibitors); block the enzyme that inactivated dopamine making Levodopa last longer

Monoamine oxidase type B inhibitor (MAOI)- selegline; used for mild symptoms to increase dopamine concentrations

Amantadine, rivastigmine

Drug holiday: drug toxicity can manifest as confusion and delirium. Decrease the dose or change drugs; stop all Parkinson’s drugs for 10 days of tolerance is built up and aren’t working. Monitor for worsening S/S: gait, speech, swallowing, look for UTI related to urinary incontinence, etc.

54
Q

MAOIs

A

No barbiturates, tricyclics antidepressants, antihistamines, CNS depressants, anti hypertensives, OTC cold meds

No cheese, wine, pickled foods

Can cause sweating, tremors, dizziness, high BP, pounding or fast HR

55
Q

Parkinson’s therapy

A

PT & OT to maintain strength, balance, and flexibility

Dietician- nutrition evaluation
Ensure they are getting enough protein (related to edema), calcium (related to fall risk), Vit K (related to bleeding and bruising

Speech language pathologist- swallow evaluation and speech communication plan
May need thickened liquids if trouble swallowing thin liquids- tend not to drink as much thickened liquids and are at risk for dehydration; soft diets if trouble chewing; cold fluids (e.g., milkshakes) tend to go down easier; allow them to speak- do not speak for them

Psychosocial- memory deficits with social work and case management

56
Q

Parkinson’s surgery

A

Stereotactic pallidotomy- probe placed and stimulation applied; permanent scar made; scar formation done to slow down Ach effect because there is less dopamine; will do this where they see decrease in tremor upon probe placement; patient needs to be conscious of what is going on

Deep brain stimulation- place electrodes (one or two) in these subthalamic nucleus area which connects to a lead which connects to a pulse generator under the clavicle. An electrical current is sent to the electrode to reduce some involuntary movement and tremors

57
Q

Spinal cord injury

A

Assess sensation along dermatome and proprioception

Stabilization with halo (cervical), ORIF (thoracic), TLSO (lumbar/sacral)

Airway clearance- cough assist, suction
Immobility
Elimination of neurogenic bladder/bowel (follow catheter schedule, bowel program)
Skin assessment and care

Breakfast at 8am (8 cervical)
Lunch at noon (12 thoracic)
Dinner and dessert at 5 (5 lumbar and 5 sacral)

Everything below injury is affected, unless complete sever- then entire spinal cord is affected.

Quadriplegia: typically includes respiratory
Tetraplegia: arms and chest
Paraplegia: midthoracic and below, doesn’t affect the chest

58
Q

Autonomic Dysreflexia

A

Higher than T6 injury
Uncontrolled sympathetic output (severe HTN, bradycardia, severe HA, nasal stuffiness, flushing, distended neck veins, sweating; dilation above and constriction below- pale, cool, no sweat)
Cause- noxious stimuli; triggered by sustained stimuli at T6 or below from restrictive clothing, full bladder or UTI, pressure areas, fecal impaction
Nursing care- sitting position, call help, loosen clothing, assess bladder distention or fecal impaction, BP Q10min, hydralizine per order

59
Q

Spina bifida

A

Failure of neural tube closure by 4-6 weeks; typically do not close due to a lack of folic acid and can be a part of congenital anomalies

3 Types:
Spina bifida occulta: lack of spinous process to form; meninge and spinal cord are intact; sometimes there is decreased nerve conduction but usually motor function is all there; there is a sacral dimple where the spinous process is missing.
Meningocele: spinal cord intact but meninge is outpouched through area of damage; can be some lack of sensory perception, have most motor control depending on which nerves are affected; can have poor conduction because there isn’t a tight space against the spinal cord.
Myelomeningocele- contains part of the spinal cord; don’t know what functions intact until growth occurs; below the level of injury tends to be flaccid (soft, hanging loose or limp) if not innervated; may not grow quickly; legs often shorter and smaller.

Management- initially: prevent infection, surgical repair, assess for hydrocephalus
Orthopedic- prevent contractures, equinovarus, bracing for walking support
GU- neurogenic bladder
Bowel- diet, bowel program

Latex allergy

60
Q

Multiple sclerosis (MS)

A

Immune-mediated inflammatory demyelinating disease of the CNS with plaque formation; demyelination slows the impulse and conduction and transmission of the nerve.

Some have mild form where they go back and forth from exacerbation to remission; others continue to worsen and don’t get better

Onset between 15 and 50 years old

S/S: optic neuritis, clumsiness and muscle weakness, paresthesias, Lhermitte sign, numbness and tingling, HA, cognitive dysfunction, depression, speech/swallow problems, breathing problems, fatigue, sexual dysfunction, muscle spasms, itching, walking difficulty, tremor, seizures, bowel dysfunction, bladder dysfunction, pain, hearing loss, emotional changes, vision problems, dizziness

Tx: corticosteroids, beta interferons 1A and 1B, and glatiramer acetate

61
Q

MS meds: for immunosuppression

A

Immunomodulator- figolimod (risk- bradycardia, flushing, GI); inhibits immune cells and has antioxidant brain production part- check heart rate before taking

Antineoplastic- mitoxantrone, cyclophosphamide, MTX (used during relapses)- used during relapses; five at hospital or at IV infusion center because of side effects like leukemia, cardiac toxicity, hair loss, bladder irritation, etc.

Monoclonal antibody- natalizumab (risk- viral brain infection, allergy/anaphylactic reaction); high risk for allergic and anaphylactic reactions and should be given at hospital or IV infusion center; useful for many autoimmune disorders

Corticosteroids- methylprednisolone, adrenocorticotropic hormone; used for immunosuppression

Immunosuppressants make patient at risk for infection, cancer, etc.

62
Q

MS: maintaining mobility and managing symptoms

A

Spasm- baclofen, diazepam (careful with excessive fatigue and weakness), dantrolene (to relax muscles)

Parasthesia- carbamazepine (antiepileptic), TCA (tricyclics antidepressant)

Ataxia- propranolol (works at some beta symptoms), clonazepam (decreases ataxia)

Exercise- stretch and strengthen; avoid over-heating because heat exacerbates S/S: AC can help them feel better; keep muscles moving

Cognitive impairment- attention, memory, problem solving, decrease distractions

Speech- swallow; SLP; assess risk for aspiration

Bladder- oxybutynin, intermittent cath, bladder pacemaker; from hyperreflexive bladder (anticholinergics like oxybutynin to relax)

Bowel- water, fiber, osmotic agent, enema, suppositories; from constipation (miralax, magnesium)

Vision- diplopia- eye patch to decrease double vision; peripheral vision (move head), corrective lenses

Sexual dysfunction- sildenafil, clitoral stimulation device

Depression- cognitive therapy antidepressants

CAT- massage for pain, acupuncture for tremor, yoga for strengthening, meditation, aromatherapy

63
Q

Sinus headache

A

Pain usually behind the forehead and/or cheekbones

64
Q

Cluster headache

A

Pain in and around one eye

65
Q

Tension headache

A

Pain is like a band squeezing the head

66
Q

Migraine

A

Pain, nausea, and visual changes

Lasts 4-72 hours
More in females
Unilateral, frontotemporal, throbbing
Aura- may see squiggles, smell something, etc.
Photophonia, photophobia
N/V
Abortive therapy- acetaminophen, NSAIDs, triptans, ergotamine, isometheptine

Prevent- beta blocker, topiramate (antiepileptic), may also do Botox to help relax muscle around muscle spasms

Vicodin will help but causes rebound affect where migraine will come back worse and can contribute to opioid abuse and overuse

Identify triggers- keep diary

67
Q

Hydrocephalus

A

CSF imbalance (production or absorption), absorption, or flow problem; anything blocking the flow of CSF can cause hydrocephalus

Causes dilated ventricles in the head; bones pull apart in children and head continues to grow and fill with more bone; bones never fuse. In adults, the bones are fused and head won’t grow but will have signs of headache.

Diagnosis: change in head circumference, signs of increased ICP, CT, MRI

Tx: VP shunt, VA shunt, L-P shunt

68
Q

Ventricular peritoneal (VP) shunt

A

Most common

Catheter is placed into the ventricle, there is a button on the head which is a pressure valve. When the pressure inside the ventricle is higher than the pressure in the valve, it releases CSF to the peritoneum where it is then reabsorbed. Do not want it to drain outside the body because there is fluid loss that would normally be reabsorbed. They can coil a lot of cord into the brown area of the abdomen so when they grow, it unravels so they do not have to have it constantly replaced. Once the occipital bones fuse together, they will have more S/S of a headache. If they have to constantly replace it due to clogging, they will do a VA shunt

69
Q

VA shunt

A

Goes into the atrium which allows for more flow

Not as common because they don’t want to mess with the heart if they don’t have to

70
Q

Lumbar peritoneal shunt (L-P)

A

Done in kids with too much production

Catheter is inserted into the lumbar area with a valve that senses if the pressure is too high above and will release it into the perineum

71
Q

Craniosynostosis

A

Plagiocephaly- abnormally shaped head; sutures and fontanels still open but head is misshaped; back of head very flat

Abnormal closure of sutures/ fontanels or born with closed suture line or fontanel; brain cannot grow symmetrical. Apert syndrome is common for craniosynostosis to occur; need to repair this. If completely fused: surgical repair as an infant. If not fused but worried about unsymmetrical brain growth, wait until 1 or 1.5 y/o to surgically repair.

Causes abnormal brain growth without repair

Helmet for mild to apply pressure and reshape head; on for 23 hours of the day

Surgical repair- ear to ear incision, pull back skin, cut apart bones, reshape to round shape, put back together

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