By: Diana Blum Msn

NURS 2150

Metropolitan Community College

Neuro/musculoskeletal

Selective Anatomy 12 cranial nerves 31 spinal nerves

Neuron transmits impulses to facilitate movement or sensation

Meninges serve as protection of the brain and spinal cord

Bronca’s area in frontal lobe forms speech

Hypothalamus regulates water, appetite, temp

CSF: surrounds and cushions brain and cord

Physical assessment Orientation

LOC

Memory◦ LTM (DOB)

◦ STM (mode of transportation to hospital)

◦ Immediate memory (repeat 3 words after 5 minutes)

Attention◦ Serial 7 test

Language/copying◦ Follows simple commands

Cognition ◦ Current events

functional Assessment Appearance

Speech

Motor function

Family history

Ethnicity

Diet

ADLs

Right handed or left handed◦ Brain injury is more pronounced in dominant hemisphere

Sensory assessment Pain and temp

◦ Cotton ball vs paper clip

◦ Cold vs warm

Touch◦ Pt closes eyes and you touch hand etc and then have them touch

where you touched

ABNORMAL FINDINGS Propioception-position sense below injury Contralateral- loss of sensation in opposite side of body

affected

Motor assessment Hand grasps

Foot strength

Arm drift

Coordination

Gait

Balance

Reflexes

ABNORMAL FINDINGS

tremors, weakness, paralysis, jerking muscles

Rapid assessment Glascow coma scale: eye opening, motor response, and

verbal response◦ painful stimuli

Supraorbital pressure Sternal rub Mandibular pressure Trapezius squeeze

◦ LOC Decortication-hands/arms turned in Decerebration- hands/ arms turned out

◦ Pupil assess Response to light

The GCS is scored between 3 and 15, 3 being the worst score, and 15 the best.

It is composed of three parts: Best Eye Response, Best Verbal Response, Best Motor Response

When doing a neuro assessment it is important to watch for trends indicating a decreasing LOC.

Keep in mind that when patients have ingested alcohol,

mind altering drugs, have hypoglycemia or shock with a systolic BP <80, the GCS may be invalid.

9 to 12 is a moderate injury

8 or less is a severe brain injury.

  7 or less = Coma

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

Sleepy or drowsy

Stuporous

Fully alert and oriented

Comatose

This is testable material.. So read CHAPTER 20

That was review from nurs 2520 and A&P

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

Types of Seizures

Tonic-Clonic: lasts 2-5 minutes• Rigidity/stiffening arms/legs and Loss of Consciousness cyanosis excess

drooling

Tonic: loss of consciousness, muscle contraction and relaxation

Clonic: rhythmic jerking, may bite tongue, incontinence• Post seizure lethargy

Absence: more common in kids, runs in families, blank staring, loss of consciousness (resembles daydreaming)

Myoclonic: brief jerking or stiffening, symmetric or assymetric movement

Atonic (akinetic): sudden loss of muscle tone, lasts for few seconds confusion after seizure.

Partial: begin in one part of cerebral hemisphere, most often in adults and are less responsive to medical treatment

Complex Partial: blacks out for 1-3 minutes and automatisms present (lip smacking, picking), amnesia after seizure,temporal lobe most affected

Simple partial: remains conscious, senses unusual sensation, smell, or pain before (déjà vu). Unilateral movement during seizure, and may have tachycardia, flushing, or psychic symptoms

Idopathic: account for ½ of seizures, no known cause

Causes Metabolic disorders

ETOH withdrawl

Electrolyte disturbances

Heart disease

Altered gene function• Defective genes for

channels that regulate ions in/out of cell

• Myoclonus clients are missing cystain B protein

• Etc.

Triggers• Physical activity• Stress• Fatigue• Alcohol or caffeine• Certain foods

Epilepsy Def: chronic disorder characterized by recurrent unprovoked seizure activity.• May be caused from abnormality in electrical neuronal activity,

abnormal transmitters, or both.

Approximately 2 million people in the USA with epilepsy

can be defined as abnormal, uncontrolled electrical activity in brain cells.

Nerve cells transmit signals to and from the brain in two ways by • (1) altering the concentrations of salts (sodium, potassium, calcium)

within the cell

• (2) releasing chemicals called neurotransmitters (gamma aminobutyric acid). The change in salt concentration conducts the impulse from one end of the nerve cell to the other.

Types of Epilepsy

Primary or idopathic• Not associated with identifiable brain lesion

Secondary • Most common cause is brain lesion, tumor or trauma

Status epilepticus• Prolonged seizures that last greater than 5 minutes or repeated seizures over the course of thirty minutes.• Causes:

• Med withdrawl• Infection• Acute alcohol withdrawl• Head trauma• Cerebral edema• Metabolic disturbances

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

Education of seizure/epilepsy patient

Teach importance of taking meds as prescribed

Promote balanced diet, rest, and stress reduction techniques

Instruct pt. to keep a seizure diary to identify causative factors

Phases of seizures

Preicteral phase: aura present.. The first phase involves alterations in smell, taste, visual perception, hearing, and emotional state. This is known as an aura, which is actually a small partial seizure that is often followed by a larger event.

Ictus: The seizure.. There are two major types of seizure: partial and generalized. What happens to the person during the seizure depends on where in the brain the disruption of neural activity occurs.

Postictal state: The period in which the brain recovers from the insult

it has experienced. Drowsiness and confusion are commonly experienced during this phase. the period in which the brain recovers from the insult it has experienced

TREATMENTNonsurgical• Antiepileptic drugs• Seizure precautions

• During: • Protect the client from injury• Do not force anything into

mouth• Turn client to side• Loosen restrictive clothes• Do not restrain

• After• Take vitals• Perform neuro checks• Keep on side• Allow rest• document

Teach family• Info about disease• Info about medication• Support groups available• Teach about alcohol

avoidance• To investigate state laws

pertaining to driving and working with machinery

• Care of seizure client

Surgical treatmentVagal nerve stimulation• For simple or complex partial seizures• Stimulating device is surgically placed in the left chest wall with a lead wire on the vagus nerve

• Activates with hand held magnet

Corpuscalostomy• Used for tonic-clonic seizures• For those not candidates for other surgical procedures• Sections of the anterior and 2/3 of the corpus collosum are created to prevent neural discharges

Nursing diagnosisRisk for falls

Ineffective coping

Risk for ineffective breathing

HUNTINGTON’S DISEASEFormerly huntington’s chorea

Hereditary

Transmitted as an autosomal dominant trait at time of conception

25000 people in usa have

2 main symptoms are progressive mental status changes and choreiform movements (rapid, jerky) in the limbs trunk and face

No known cause

No known treatment

Only prevention is to not have children

Antipsychotics and monoamine depleting agents used to manage movement

TX: PT, OT, speech therapy, meal planning by dietician, HHC, social work to line up community resources

Osteoporosis

Metabolic condition

Bone demineralizes

Easy to fracture

Wrist, hip, and vertebrae are most affected

Osteopenia: low bone mass

Osteoclasic: bone resorption

Decreased bone mineral density

40-45% loss in women throughout lifespan

Trebecular (Spongy bone) is lost first

Then Cortical (compact bone) lost 2nd

Pathophysiology is unknown

classesGeneralized:involves many structures• Primary: more common

• Post menopausal women

• Men in 60s-70s

• seconday

Regional: limb involved• r/t fx, injury, paralysis, joint inflammation

• Immobilization greater than 8-12 weeks

• Weightless environment (astronauts)

Health preventionTeach about exercise

Teach about diet rich in calcium

Teach about bone health

Teach about safety

Assessment Risk for falls

Head to toe assessment• Inspect and palpate vertebrae

Assess pain

Assess for fallophobia

No definitive lab tests

Bone scan to check density

Nursing diagnosisRisk for falls

Impaired physical mobility

Acute or chronic pain

InterventionsClient education is #1

Hormone replacements

Calcium supplements

Multivitamins

Diet

Fall prevention

Exercise

Pain management

Braces

Osteomalacia Softening of the bone tissue

Inadequate mineralization of osteoid (mature compact and spongy bone)

Vitamin D deficiency is a key player

Similar characteristics with osteoporosis

Rare in USA

Prevent with vitamin D, sun exposure, and diet

s/s: early stages : nonspecific• Muscle weakness

• Bone pain

• Hypophosphatemia

• Hypocalcemia

• Generalized bone tenderness

Paget’s Disease

Metabolic disorder of bone remodeling

Bone deposits that are weak, enlarged, and disorganized

Phases:• Active increased osteoclasts cause massive bone destruction• Osteoclasts are multinuclear

• Mixed• Inactive 2nd phase

• New bone becomes sclerotic and very hard

• Osteoclasts return to normal amount

2nd most common bone disease

Most common sites are vertebrae, femur, skull, sternum, and pelvis

Unknown cause

Assessment 80% asymptomatic

Assess past history of fractures, skin color and temp, gout, hyperparathyroidism, lethargy, hyperuricemia

Pain that is aching, deep, poor description

Pain worsens with weight bearing and pressure

Pain most noticeable at nite or at rest

Arthritis at infected joints

Assess posture, gait, and balance

Assess vision, speech, and swallowing, hydrocephalus,

Neoplasm is the dreaded complication

Diagnostics Serum alk phosphate• Those treated for paget’s need ALP drawn 3-4 times/year

Urine hydroxyproline• Shows bone collagen turnover and degree of severity

Calcium levels are normal or elevated

Increase noted in uric acid• May initially be thought to be gout

X-rays, CT, MRI, bone biopsy

Treatment

Drugs for pain relief

Drugs to decrease bone resorption

Calcitonin (thyroid hormone)

Mithramycin (antineoplastic)

Biphosphanates

Heat therapy

Gentle massage

Exercise

PT

Diet

Osteotomy or joint replacement

osteomylelitis

Inflammatory process

Increase in vascularity and edema

Vessel becomes thrombosed once inflamed

Ischemia is next

Then necrosis

Sequestrium forms and retards bone healing

Categories Exogenous: infection enters from outside

Endogenous: infection enters from inside

Contiguous: results from skin infection

The most common offending organism is pseudomonas aeruginosa

Staph, salmonella are aslo culprits

s/s and assessmentPain

Fever

Erythema

Heat

Swelling

Assess circulation

Assess for septic shock

Treatment Contact precautions

IV antibx therapy

PICC line

Use sterile techniques

Pain meds

Hyperbaric oxygen therapy

Bone grafts

Muscle flaps

Amputations

Bone tumors

Chondrogenic Osteochondroma: most common, benign, tumor…onsets in childhood, grows until skeletal maturity..has a bony stalk like appearance..may become malignant

Chondroma: lesion of mature hyaline cartilage of the hand and feet. Ribs, sternum, spine, and long bones can also be affected…can get at any age or gender

Osteogenic Osteoid osteoma: pinkish granular appearance..any bone affected..femur and tibia most affected

Osteoblastoma: affects vertebrae and long bones..large in size and lies in spongy bone..reddish granular appearance

Giant cell tumor: origin unknown..aggressive and extensive..affects women 20s-30s

Assessment/ tx Assess pain

Palpate involved area

CT scan and MRI done for diagnosis

Interventions• Meds and surgery combination

• Pain meds

• Meds taken with meals or milk

•

Malignant bone tumorsPrimary: originate in bone / 2nd ary: mets to bone

• Primary

Osteosarcoma: most common

• Large lesion, pain and swelling of short duration, warm site, central portion is sclerotic, usually mets to lung in 2 yrs then death

Ewing’s sarcoma: most malignant

• Pain and swelling, fever, anemia, leukocytosis, pelvis and lower extremities most affected, any age..but kids and young adults age 20s more

• Pelvic yields poor prognosis

Chondrosarcoma: dull pain, swelling for long period..• pelvis and femur fore affected

• Destroys bone and often calcifies

• Affect middle age to elders and more in men

Fibrosarcoma: from fibrous tissue; most common in long bones of legs and mets to lungs• Histiocytoma is most malignant type

• Local tenderness, with or w/o mass palpated

Bone Mets Primary tumors are in prostate, breast, kidney, thyroid, and lung

Fractures are major problem with management• Femur and acetabulum

Primarily affects those under 40

Assess/ diagnostics

Assess pain, swelling, palpate for masses

Monitor vs

Assess ADLs

Assess support structures

Assess coping skills

Check ALP levels for elevation

CT scan

Stage tumor

Nursing diagnosis/tx Pain

Anticipatory grieving

Disturbed body image

Fear

Anxiety

Tx• Pain management, chemo, radiation, surgery, dressing changes, be

active listener, establish goals, safety precautions, HHC

Carpal Tunnel

Education Use ergonomic work stations

Teach client to take regular breaks

s/s• Parathesia in hands

• Weak pinch, clumsiness, weakness

• Hand activity worsens symtoms

• Swelling may occur

Tx: nsaids, surgery

Dupuytren’s contracturesSlow progressive contracture

Common problem

Affects 4th or 5th digit of the hand

Trigger finger release surgery performed to fix

Disorders of the foot

Hammertoe: fix with surgery

Tarsal tunnel syndrome: ankle version of carpal tunnel

Plantar fasciitis: inflammation of the plantar fascia located in the arch of the foot• s/s: pain in arch, pain worsens w/ wt bearing

• Tx: ice, rest, stretches, strapping, nsaids, surgery

Hallux valgus: aka bunion

Associated with 8th cranial nerve or cellebellum

Menieres disease is an example of a disorder of vertigo.

most common 30-60

Ultimately just means dizzy

Vertigo

The brain Headaches pg 506

◦ 3 MAIN types Migraine-genetic predisposition

s/s: sensitive scalp, anorexia, photophobia, N/V Spasming of arteries at the base of the brain causing arterial

constriction, decrease cerebral blood flow, platelets clump, and serotonin released. Other ateries release prostoglandins that cause swelling and inflammation

With aura- sensation that signals onset Most are without aura Atypical- less common Tx: tylenol, migraine medicine, beta blocker, yoga, meditation,

relaxation, etc.

Cluster headache one sided headache usually felt deep around eye. They

come and go

Onset is associated with relaxation, napping or REM sleep

s/s: ipsilateral (one side) tearing of the eye, rhinorrhea(runny nose), ptosis(droopy), eyelid edema, facial sweating, miosis (abn. Constriction of eye). There may be bradycardia, pallor, increased temp.

Tx: same as migraine, wear sunglasses, O2 for 15 minutes, surgery

Tension headacheMuscle and shoulder tenderness, base of skull and forehead pain. Similar s/s to migraines

Classic s/s:N/V, photophobia, phonophobia, aggravates with activity

Tx: NSAIDS,muscle relaxers

Parkinson’shttp://www.youtube.com/watch?v=TtM-aP9Gr28

Alzheimer’s Diseasehttp://www.youtube.com/watch?v=Z6lA1P2tF0o&feature=related

Stages Early• mild

Middle• moderate

Late• severe

s/sAggressive

Rapid mood swings

Increased confusion at nite (sundowner’s)

Decrease interest in personal appearance

Inappropriate clothing selection

Loss of bowel/bladder

Decreased appetite

diagnosis

CBC

BMP

Folate level checked

Thyroid and liver function test

Test for syphilis

Drug tox screening (OTC)

Alcohol screening

CT

MRI

PET

EEG

Nursing diagnosisChronic confusion

Risk for injury

Disturbed sleep pattern

Tx

Meds

Prevent overstimulation

Be consistent

Reorient

Promote independence

Bowel/bladder training

Promote facial recognition

Speech therapy

Safety precautions

Minimize agitations

http://www.youtube.com/watch?v=Xv1tMioGgXI

Monitor electrolytes especially sodium levels and protein levels

Chart 8-2 talks about labs to monitor– albumin transferrin---prealbumin total lymphocytes.

Diets chart 8-4

Nutrition

glaucoma

2 types• Primary open angle: most common

• Angle closure: less common..emergency

s/sOpen angle: small cresent shaped defect

Angle closure: visual fields quickly decrease, severe pain around eye, headache, n/v, halos, blurred vision

Macular degenerationCentral vision declines

Mild blurring or distortion

More rapid to produce in smokers

Spinal Cord Injury(SCI)

Chapter 24

Causes of SCIPrimary

• Hyperflexion (moved forward excessively)• Hyperextension (MVA)• Axial loading (blow at top of head causes shattering)• Excessive rotation (turning beyond normal range)• Penetrating (knife, bullet)

Secondary

• Neurogenic shock• Vascular insult • Hemorrhage• Ischemia• Electrolyte imbalance

Types

Complete: spinal cord severed and no nerve impulses below level of injury• Cervical/Thoracic

Incomplete: allow some function and movement below level of injury• Includes:• Central cord syndrome • Anterior cord syndrome• Brown-Séquard syndrome

CompleteTetraplegia (quadriplegia): paralysis from neck down• Loss of bowel and bladder control

• Loss of motor function

• Loss of reflex activity

• Loss of sensation

• Coping issues

*Christopher Reeve is example of this injury*

IncompleteCentral Cord Syndrome• Hyperextension damage to center of spinal cord

• Greater loss of function in upper extremities

Anterior Cord Syndrome• Cause: Direct injury to anterior spinal cord or disrupted anterior spinal

artery

• Paralysis, loss of pain and temperature sensation

• Light touch, vibration, proprioception preserved

• Prognosis for recovery is variable

IncompletePosterior cord lesion• Damage to posterior white and gray matter• Motor function intact, but loss of vibratory sense, crude touch, and

position sensation

Brown Sequard syndrome• Result of penetrating injury that causes hemisection of spinal cord.• Motor function , proprioception, vibration, and deep touch are lost on

the same side as injury (ipsilateral)• On the other side (contralateral) the sensation of pain, temperature

and light touch are affected

Assessment1st -respiratory status

2nd - intra-abdominal hemorrhage (hypotension, tachycardia, weak and thready pulse)

3rd assess motor function

• C4-5 apply downward pressure while the client shrugs• C5-6 apply resistance while client pulls up arms• C7 apply resistance while pt straightens flexed arms• C8 check hand grasp• L2-4 apply resistance while the client lifts legs from

bed• L5 apply resistance while client dorsiflexes feet• S1 apply resistance while client plantar flexes feet

ComplicationsCerebral ischemia

DVT/PE

Pneumonia/Atelectasis

Vomiting and Aspiration

GI stress ulcers

Constipation

UTI

Pressure Ulcers

Autonomic DysreflexiaSevere HTN, bradycardia, sever headache, nasal stuffiness, and flushing

• Caused by noxious stimuli like distended bladder or constipation

Immediate interventions

• Place in sitting position• Call doctor • Loosen tight clothes• Check foley tubing if present• Check for impaction• Check room temp• Monitor BP q10-15 minutes• Give nitrates or hydralazine per md order

TreatmentImmobilize fx- C-collarProper body alignment• Traction is possible

Monitor VS q4 hr and prnNeuro checks q4 hr and prnMonitor for neurogenic shock (hypotension and bradycardia)Prepare for possible surgeryTeach skin care, ADLs, wound prevention techniques, bowel and bladder training, medications, and sexuality

NRSG DX for SCI

Ineffective tissue perfusion r/t interruption of arterial flow

Ineffective airway clearance r/t SCI

Ineffective breathing pattern r/t SCI

Impaired gas exchange r/t SCI

Traumatic Brain Injury(TBI)

Head Injury Classification:

Severe Head Injury----GCS score of 8 or less

Moderate Head Injury----GCS score of 9 to 12

Mild Head Injury----GCS score of 13 to 15

(Adapted from: Advanced Trauma Life Support: Course for Physicians, American College of Surgeons, 1993).

Superficial InjuriesCommon

Abrasions

“Goose Eggs”

Lacerations• Scalp is very vascular

Xray if suspect skull fracture

Skull FracturesCategorized according to type and severity

Frequently seen in conjunction with brain injuries

Linear skull fractures

Comminuted skull fractures

Basal skull fractures

Possible associated cranial nerve deficits

Open Skull FracturesLinear- simple clean break

Depressed - bone pressed in towards tissue

Open -lacerated scalp that creates opening to brain tissue

Comminuted - bone fragments and depresses into brain tissue

Basilar- unique fx at base of skull with CSF leaking though the ear or nose• Racoon eyes/Battles sign

http://www.pearlau.com.au/jpg/raccoon%2520eyes%

http://www.pearlau.com.au/jpg/raccoon%2520eyes

Closed Skull FracturesClosed- blunt trauma • Mild concussion-brief LOC• Diffuse axonal injury- usually from MVA • May go into coma

• Contusion-bruising of brain• Site of impact (coupe)• Opposite side of impact (contrecoupe)

Intracranial HematomasEpidural- bleed b/w skull and dura• Laceration of artery or vien

Subdural-bleed below dura and arachoid layers • Acute, subacute, chronic

Intracerebral-accumulation of blood in brain tissue• Blunt trauma

• Penetrating wounds

• Acceleration/deceleration injuries

Increased Intracranial Pressure(ICP)

Pg 568

Increase is caused by an increase in the volume of any of the intracranial components

Drivers of increased ICP• Hypoxia – triggers the vasodilatory cascade

• Ischemia in acute brain injury

Increased ICPNormal ICP 10-15mmHg

Normal increases occur with coughing, sneezing, defecation

Leading cause of death for head trauma

As ICP increases cerebral perfusion decreases causing tissue hypoxia, decrease serum pH, and increase in CO2

ICP continued3 types of edema• Vasogenic: increase in brain tissue volume

• Cytotoxic: result of hypoxia

• Interstitial: occurs with brain swelling

Assessment

Hydrocephalus

abnormal increase in CSF volume

Causes: impaired reabsorption from subarachnoid hemorrhage or menengitis

Brain HerniationIncreased ICP will shift and move brain tissue downward

Central Herniation• Downward shift to brainstem

• S/S• Cheyne stokes , pinpoint pupils, hemodynamic instability

The most life threatening is Uncal because it causes pressure on the 3rd cranial nerve• S/S

• Dilated, nonreactive pupils, ptosis, rapidly decreased LOC

Herniation syndromes.

Movement/musculoskeletal

Rheumatoid Arthritis

Most common connective tissue disorders

Most destructive to joints

RA factors looked for in lab

Assess sedrate

Assess immunoglobins

MRIs performed

EMGs are performed to measure function

Assessment/ S/S continued

Joint stiffness

Swelling

Pain

Fatigue

Weight loss

Reddened joints

Deformity of joints

Baker’s cysts may occur and cause pain

Dry eyes, dry mouth, dry vagina

Assess ADLs, coping, pain

interventions

Nsaids

Immunosuppressive drug

Rest

Proper positioning

Pain management

Ice

Heart parafin wax

Plasmapheresis

Fish oil tablets

GoutType of arthritis

Urate crystals deposit in joints

Primary gout is most common

Inflammation is key sign

2nd ary is when too much uric acid in blood

Can affect kidneys

Meds to treat

Pain management

Fibromyalgia

Chronic pain syndrome

Pain is burning or gnawing

Headache and jaw pain are also common

Chest pain is common

Pain control is the key• Muscle relaxers, nsaids, antidepressants

Muscular distrophies9 types

Progression is slow or fast

Most common is severe X linked recessive

Diagnosis is difficult

Comfort is key

Treat symptoms

AMPUTATION REVIEW

amputations

Removal of part of the body

Types• Surgical-example digit

• Traumatic- example digit

Levels• Lower extremity: digits, bka, aka,

midfoot

• Upper extremity: hands, fingers, arms

Complications• Hemorrhage

• Infection

• Phantom limb pain: perceive pain in the amputated limb

• Immobility

• Neuroma: sensitive tumor consisting of nerve cells found at several nerve endings

• Contractures

Review Meds on 599-604

Review cranial nerves

TIPS!!