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111 Cards in this Set

  • Front
  • Back
Aterial
Epidural
Veins
subdural
Synapse
travelling from one cell to another,
UMN - Upper Motor Neurons
Brain to spinal cord - unable to leave the spinal cord.
LMN - Lower Motor Neurons
Spinal cord and rest of the body except cranial nerves 1, II, VIII
Reglan
Used for decreased nausea and vomiting. Decreased symptoms of gastric stasis . Side effects are: drowiness, extrapyramidal reactions, restlessness tachycardia, bradycardia hypertension, hypotension and dry mouth.
Assessment - History of medication
OTC, Herbal meds everything that the patient is taking
Assessment -Growth and Development
injuries, where they were and where they have been
Assessment -Head Injury
loss of conscousness - Very Important - epidural - arterial bleed.
Assessment -Headaches
Use scale 0-10, Where is it?
Where is it located?
When did it start?
Associated symptoms?
Always start with the worst scenerio and go down.
Assessment -Dizziness
Not able to hold onto the world
Assessment -Vertigo
"room is spinning"
Assessment -Syncope
Passing out
What concerns are there with a Seizure?
The duration, safety and maintaining airway.
What concerns are there with Dysphagia
Dysphagia is difficulty swallowing - Obstruction airway - altered nutrition - and NPO
What concerns are there with Parasthesias?
Parasthesias is numbness and tingling - think numb foot - always check if the same on both sides - symmetry and trends.
What are the Five point Neuro check?
1-Behavior - restless, irriable
2-Speech - slurring3
3-Content - person place & time
4-Arouseabilty - voice, tactile
5-Systolic BP - triad - three symptoms that occur as you watch : Systolic will go up and diastolic go down, heart rate goes down, what is baseline?
what is it now?
where is it going?
What concerns are there with Cerebellar>
gait - walk a straight line - arm swing and unequal steps
What is myelin?
think of a paved street - makes an easy transition- a sheath that covers the axon of a neuron.
What are Glial cells?
It is the glue that holds everything together - Glia means glue in Greek
Synapse
traveling from one cell to another
Neurons
–Motor
–Sensory
Receive and transmit information
Glial Cells(major cellular component)
commonly called neuroglia or glia, (GLUE)
non-neuronal cells
–Provide support
–Nutrition
–Maintain homeostasis- clean up waste/breakdown dead neurons
–Form myelin,
–Key to blood/brain barrier
–participate in signal transmission in the nervous system,
Synapse (cont)
–Neuron to neuron
–Neuron muscle/gland
Neurotransmitters
–Excite
–Inhibit
THE BRAIN
The Meninges
Are the coverings:
–Dura (outer layer)
–Arachnoid (middle layer)
–Pia mater (inner layer)
THE BRAIN
The Spaces
–Epidural
–Subdural
–Subarachnoid
THE BRAIN
Diencephalon
–Thalamus
–Hypothalamus
–Pituitary gland
THE BRAIN
Brain Stem
Midbrain
Pons
Medulla
THE BRAIN
Cerebellum
–Muscle tone/balance
–coordinated muscle movement
Spinal Cord
“conduction pathway”
 Foramen magnum to L1-L2
H - shaped mass
–Grey matter (cell body)
–2 horns
Spinal cord -
Posterior
(Dorsal) sensory- afferent
Spinal cord -
Anterior
(Ventral)-motor-efferent
Spinal cord -White matter
White matter surrounds horns
–Myelinated nerve fibers
–Arranged in “tracts”
Nerve Transmission
“The Tracts”
The motor cortex
Upper motor neurons (UMN)
starts in motor cortex
–Crown to internal capsule
unable to leave the spinal cord
lower motor neurons (LMN)
cranial and spinal nerves
–Except cranial nerves I, II, VIII
–cell bodies in the brain stem
–axons leave to the body
–Messages sent to the target organ
Pyramidal Tracts
Pyramidal tracts-(descending motor tracts)
Group of nerve fibers that carry
–VOLUNTARY MOTOR MOVEMENT to LMN
–Fine/skilled movements in skeletal muscle
–Long = rapid transmission
–Cross at the pyramids of the medulla
85% CONTRALATERAL (lateral)
15% IPSILATERAL(direct) cross in lower cord area
–Corticospinal tract
fibers synapse with spinal nerves
–Corticobulbar tract
exit brain stem and synapse with the cranial nerves
Extrapyramidal Tracts
Automatic motor movement
Gross rather than fine
Indirect rather than direct (multiple synapse)

Works with the autonomic nervous system
Basal ganglia
 3 clusters of neurons
–caudate nucleus,
–putamen,
–globus pallidus)
located at the base of the brain
responsible for involuntary movements such as
–tremors
–athetosis
–chorea.
The basal ganglia are abnormal in a number of important neurological conditions including Parkinson disease .
The term "basal ganglia" refers to the fact that this region is in the "basement" of the brain
Basal ganglia
what it does-
Inhibit
“rapid firing of neurons”
Basal ganglia
–Most affect
Head
Hands
Fingers
Extrapyramidal Tracts
Automatic motor movement
Gross rather than fine
Indirect rather than direct (multiple synapse)
Works with the autonomic nervous system
Extrapyramidal Tracts
–Responsible for
Posture
Muscle tone
Facial expression
Extrapyramidal Tracts
Components
–Basal ganglia
–Red nucleus
–Substantia nigra
–Reticular formation
–cerebellum
Extrapyramidal Tracts
(problem solver)
Complex system-tracts & ganglia
–Basal ganglia, red nucleus, substantia nigra and reticular formation and cerebellum
–Function is unconscious
Act: automatically/involuntary
Gross rather than fine
–Origin is diffuse within the CNS
VOLUNTARY MUSCLE EXCITATION
Culprit:
–Gravity- posture/balance
Skeletal muscle “resting tension” or TONUS
–Prior learning – bike riding
–Compensating Movements – anticipatory postural reflexes
–Merging voluntary and involuntary
BASAL GANGLIA
–Neurotransmitters involved
Acetylcholine
Dopamine – substantia nigra
GABA ( gamma amino butric acid)
Ascending Tracts
From spinal cord to brain
The Peripheral Nervous System
Somatic
31 pairs spinal and 12 pairs cranial
****Voluntary control*****
Spinal nerves
– Arranged in segments
–Attached to the spinal cord
–Numbered by vertebral location
–Anterior root – motor
From cord to muscle or gland
–Posterior root – sensory
–Dorsal route ganglion
–Relay sensor input to the cord
Cranial Nerves
12 pairs of cranial nerves
Sensory
Motor
Sensory motor
The Autonomic Nervous System
not voluntary
The Autonomic Nervous System
Sympathetic
“fight or flight”
–adrenergic
The Autonomic Nervous System
Parasympathetic
“rest and digest”
–cholinergic
Focused Neurological
History
Present illness/ Review of systems
Current medications
Growth and development
Head injury?
–Loss of consciousness
–Details- when , where, how often aggravating/alleviating factors
Headaches?
Dizziness/Vertigo/Syncope
Seizure
Swallowing difficulty/ Dysphagia
Speech / Disarthria
Coordination
Sensation – numbness of tingling / Parasthesias
Environmental/occupational hazards (insecticide/ ETOH)
Significant neurologicl history (CVA, infection)
ASSESSING THE PATIENT
THINK TRENDS and SYMMETRY
QUICK 5 POINT
NEURO CHECK
1. Behavior
Affect
Irritability
Restlessness
QUICK 5 POINT
NEURO CHECK
2 Speech
Appropriateness
Slurring
QUICK 5 POINT
NEURO CHECK
3. Content
Person
Place
time
QUICK 5 POINT
NEURO CHECK
4. Arousability
Spontaneous
voice
tactile
QUICK 5 POINT
NEURO CHECK
5.Systolic BP
Triad
NEUROLOGICAL ASSESSMENT

THE SINGLE MOST IMPORTANT ASSESSMENT
Level Of Consciousness
Full consciousness
Lethargy
–awakens, follows commands, slow , inattentive

Obtunded
–difficult to arouse, constant stimulation, few words, asleep

Stupor
–Deep stimulation ,moan, does not follow commands , may remove painful stimuli

Coma
–No verbal response, reflex action
Cranial Nerve assessment
Inspect and palpate the motor system
–Muscle size/ symmetry
–Muscle strength-use resistance method
–Muscle tone – limited ROM /pain/ flaccid/ spastic or rigid.
–Involuntary Movement- TICS /Tremors/ fasciculations
Cerebellar Function
Balance
Coordination
Skilled movements
Cerebellar Function
Check-
–Gait- walk a straight line
Stiff posture/ staggering/wide base of support/ arm swing/ unequal steps/foot slapping or ataxia
–Romberg Test
–Rapid alternating movement
–Finger to finger test
–Finger to nose
–Heel to shin
Assess the sensory system
Presence
–Pain
–Temperature
Light touch
–Discrimination
Light touch – sharp or dull
Hot and cold
Other sensory evaluation
Vibration – tuning fork
Position (kinesthesia)
Tactile discrimination
–Stereognosis
–Graphesthesia
Two point discrimination
CHECK REFLEXES
Involuntary actions in response to stimulus sent to the CNS
First sign of neurological dysfunction
–UMN LESION
–PYRAMIDAL TRACTS
SPINAL CORD INJURY
2 TYPES
–STRETCH OR DEEP TENDON (0-5+ NORMAL +2)
–SUPERFICIAL Ex: Babinski
The CAT or CT Scan
–Computerized axial tomography
–X ray in segments
–Can be made into 3D pictures
–Specialized scanners (ex)
Dynamic CT – contrast is injected into an artery
Helical or Spiral CT
The CAT or CT Scan
CONTRAINDICATIONS
–Patient status?
–Pregnancy
–Obesity
–Allergy
–Residual barium
–Cooperation/claustrophobia
- Can not give meds for two days after procedure.
-Radiation
**Can not give Glucophage** it is a medicine given fordiabetic patients
Patient Prep for CT Scan
NPO – time?
Remove anything that may obstruct scan
Educate patient / address concerns
Contrast
–Confirm order
–Assess allergies
Pre treatment
–Assess renal function
BUN/Creatinine
–Check medications –metformin (glucophage)
Stop 48 hours after test
–Initiate IV access
–Hydration
–48 hours between exams with contrast
MRI
Magnetic Resonance Imaging
Its a huge magnet.
Stimulates the body to produce different signals that correspond to different tissue characteristics
Maps changes in soft tissue
Reduce the risk associated with more invasive tests
Contrast
MRI
Magnetic Resonance Imaging
Benefits
Non-Radioactive contrast agent
Rare allergic reactions
Cleared by kidney
Enters where cell wall is compromised
MRI
Magnetic Resonance Imaging
–contraindications
Metal
Claustrophobia
Patient status
Pregnancy
Previous allergy
–Check list
–Sedative
PET SCAN
POSITRON EMISION TOMOGRAPHY
Inhalation or injection with a radioactive substance
Brain scan – pt asked to perform cognitive activities i.e. Pledge of Allegiance – measure of brain activity during reasoning or remembering
Determines level of functioning of an organ
–A/P: glucose metabolism, blood flow, tissue perfusion on specific areas
–Pathology : alteration in normal metabolic process
Exposure to radiation minimal

Radioactive tracer (RA isotope to pharm agent)
Waiting period of few minutes to few hours
Isotope releases energy (gamma rays)
PET scanner measures energy
Computer converts it to an image of metabolic activity
PET SCAN
Use
cancers/ CV/ Neurological problems
Staging disease
Metastatic spread
Effectiveness of therapy
PET SCAN
Preparation/Education
Check for pregnancy/ breast feeding
Fluids
Time
LUMBAR PUNCTURE \ LP
 LP/ Spinal tap
Needle inserted into subarachnoid
space at L2 – L3
LUMBAR PUNCTURE \ LP

Purpose
–ICP measurement
–Specimen collection
–Inject medication
Chemo
Antibiotics
Anesthesia
LUMBAR PUNCTURE \ LP
Purpose
–ICP measurement
–Specimen collection
–Inject medication
Chemo
Antibiotics
Anesthesia
LUMBAR PUNCTURE \ LP
Contraindications
Increased ICP
Infection
Coagulation defects
Degenerative joint disease
Patient cooperation
LUMBAR PUNCTURE \ LP
Procedure
Consent
Vital signs
Empty bladder
Educate – position/ sensation
LUMBAR PUNCTURE \ LP
Post procedure
Flat in bed
Headache/ nuchal rigidity
Neuro assessment
Site leakage
Fluids
LUMBAR PUNCTURE \ LP
Complications
Infection
Brain herniation
Blood patch
EMG- ELECTROMYOGRAPHY
CEREBRAL ANGIOGRAPHY
ARTERIOGRAPHY
measures electrical activity in nerves and muscles.
provides clues about nerve and muscle disorders.
determine the cause of problems such as
– muscle weakness
–spasms,
–paralysis
–pain in arms, hands, legs, feet, face.
EMG- ELECTROMYOGRAPHY
How to Prepare :
Eat regular meal
Take any medication normally taken
shower or bath to remove any body oils.
Do NOT use any bath oils, lotions, or creams where symptoms are present. Deodorant may be used
EMG- ELECTROMYOGRAPHY
What to Expect
What to Expect :
two parts
lasts from 1-3 hours.
first part nerve conduction studies.
–lying down, electrodes taped to the skin.
nerves will be stimulated on the skin
and the response will be measured.
 sensation compared to a tingle.
physician administers second part of the test.
 a small, thin, sterile disposable needle is inserted into the muscles to be tested.
 measures muscle's electrical activity.
patient asked to relax and contract the muscle during assessment.
After the test
minor soreness for several days.
– mild analgesic.
Ultrasound Prep
Really not too much prep - Jelly - cold
you can also use a veinous doppler to check for clots
very invasive procedure
Parkinson’s Disease
TRAP
tremor, rigidity ,akinesia, difficult maintaining posture.
Side bar -Akinesia (from the prefix a-, "without", and the Greek κίνηση, kinisi, "motion") is the inability to initiate movement due to difficulty selecting and/or activating motor programs in the central nervous system. Common in severe cases of Parkinson's disease, akinesia is a result of severely diminished dopaminergic cell activity in the direct pathway of movement.
Parkinson’s Disease
One of most crippling diseases in US
1 in every 40-50 people over 60 affected
Symptoms begin around age 60
men more than women
60,000 new case diagnosed annually in US
Increase predicted as population ages
Parkinson’s Disease
Classification: Determine Progression
Stage I: Unilateral involvement
'asymmetric rest tremor' is considered a hallmark symptom of early Parkinson's disease. It can also affect the legs, chin, or jaw (as in a chewing motion).

Stage II: Bilateral involvement

Stage III: Impaired posture/ reflexes
Mild to moderate disability

Stage IV: Fully developed severe disease
Marked disability

Stage V: Confinement to bed or wheelchair
Cause
Parkinson’s Disease
Cause
Unknown or unclear
Genetic/environmental factors
Parkinson’s Disease
Research
Genetics – less than 50 yrs
Exogenous toxins
Manganese dust- welders disease/ early onset
Carbon monoxide
Viral agents
Clinical symptoms do not appear until 80% of the basal ganglia are destroyed
Parkinson’s Disease
The Disease Process
Basal Ganglia (sturcture deep in brain)
Connects cerebral cortex and thalamus
“ease of movement”

SUBSTANTIA NIGRA
Located in midbrain
Produces dopamine
Smooth, voluntary movement
Parkinson’s Disease
A SECOND
NEUROTRANSMITTER
Acetylcholine (Ach)
Excitatory message thru basal ganglia
Determines brain speed
Dopamine inhibits and allows
CONTROL OVER VOLUNTRY MOVEMENT

PATHOPHYSIOLOGY
degeneration of dopaminergic neurons in the basal ganglia
fine motor movement
Controls posture
Coordination of voluntary motor movement
Symptoms caused by the imbalance between dopamine (inhibits) and acetylcholine (excites)
Too much Acetylcholine =
Rigidity
Tremors
Bradykinesia
Or too little dopamine
Parkinson’s Disease
4 Cardianl signs and Symptoms (Think Trap)
Tremor
Begins in fingers (pill-roll)
Resting tremor
Increases during stress
Start unilateral
Rigidity
Resistance to muscle stretching
Cog Wheeling

Akinesia(bradykinesis)
Causes difficulty walking
Starting
Parallel
Short shuffling gait
Postural changes
Parkinson’s Disease
Other Signs And Symptoms
Tremor at rest
Rigidity- Resistance to passive movement
Cogwheel- rhythmic interruption muscle movement
Plastic- mildly restrictive
Lead Pipe- Total resistance
Bradykinesia (slowness of movement)
Hypokinesia (reduced motor reaction)
Flexed posture
Loss of postural reflexes
Freezing phenomenon
Other Signs And Symptoms
soft monotone voice
Drooling
Mask like facial expression
Facial muscle
Dysarthria
Slow monotonous slurred speech
Dysphagia
Loss of posture control
Excessive sweating
Autonomic
Decreased GI/GU function
Autonomic
Orthostatic hypotension
The PET SCAN
Positron Emission Tomography
Additonal info
Looks at dynamic process
Blood flow
Cell metabolism
Radioactive Isotopes
Short half life
Minimal radiation
Vascular Access
Decay of Isotope = release of radiation
Gamma camera takes images
Visualize concentration
Tensilon Test used for the diagnosis of MG
The Tensilon test is done by injecting the drug Tensilon into a vein and watching for rapid improvement of strength, usually of eye muscles. Improvement in strength of speech may also be considered a positive test.
A patient feeling better after Tensilon does NOT necessarily mean that the patient has MG. Blood pressure and pulse need to be monitored during the test. A patient may have MG and a negative Tensilon test (no improvement with the administration of the medication), but then the diagnosis should be supported by other tests, such as the acetylcholine receptor antibodies in the blood, or by a positive EMG test.
*Blockds the acetycholine.
Steroids - Prednisone
(MG)
used for the management of MG – It must be taken with food as the steroids tend to upset the stomach.
Immunosuppressant
Immunosuppressants
Azathioprine (Imuran), Mycophenolate (MFM or CellCept),
Cyclosporine (Sandimmune) and Mercaptopurine (6-MP)

The immunosuppressants are a class of drugs capable of inhibiting the body's immune system. Many of the agents included in this category are also cytotoxic (cell poisons) and are used in the treatment of cancer. Cytotoxic agents used as immunosuppressants include antimetabolites (azathioprine), alkylating agents (cyclophosphamide), and folic-acid antagonists (methotrexate or 6-MP). Other immunosuppressants include mycophenolate (CellCept) and cyclosporin.
Immunosuppressant
side effects
These include stomach upset, nausea, vomiting, abdominal pain, mouth ulcers, darkened urine, pale stools, jaundice (yellowing of the skin or white portion of the eyes), unusual bleeding or bruising.
A serious (and life threatening) side effect is reduced activity of bone marrow, but this can be monitored with regular blood tests.
Occasionally, patients taking immunosuppressants will develop pancreatitis (inflammation of the pancreas) some months after starting these drugs.
Anticholinesterase Drugs
several drugs that prevent destruction of the neurotransmitter acetylcholine by the enzyme acetylcholinesterase within the nervous system. Acetylcholine acts to transmit nerve impulses within the parasympathetic nervous system—i.e., that part of the autonomic nervous system that tends to induce secretion, to contract smooth muscles, and to dilate blood vessels. In preventing the destruction of acetylcholine, anticholinesterase permits high levels of this neurotransmitter to build up at the sites of its action, thus stimulating the parasympathetic nervous system and in turn slowing the heart action, lowering blood pressure, increasing secretion, and inducing contraction of the smooth muscles.
Riluzole Generic name
Rilutek Brand name
ALS Medication
Riluzole
(Rilutek, United States and Canada)
More drugs used for ALS.
Use:
Riluzole or Rilutek is used in the treatment of amyotrophic lateral sclerosis (ALS) or Lou Gherig's disease.

How It Works:
Riluzole or Rilutek inhibits glutamate release possibly by blocking sodium channels. The accumulation of glutamate seems to be involved in ALS, and Riluzole or Rilutek's action prevents the accumulation.

Side Effects:
Riluzole or Rilutek can cause nausea, vomiting, increased asthenia, and increased spasticity.

Cautions for People:
People need to know, before they use Riluzole or Rilutek, that it is not clear whether Riluzole or Rilutek is useful or not. At most, it is considered to offer a modest benefit.

Drug Interactions:
Riluzole or Rilutek, at this time, does not appear to have any significant drug interactions.
DOPAMINERGIC!!!'
Parkinsons Disease
Dopamine can be supplied as a medication that acts on the sympathetic nervous system, producing effects such as increased heart rate and blood pressure. However, because dopamine cannot cross the blood-brain barrier, dopamine given as a drug does not directly affect the central nervous system. To increase the amount of dopamine in the brains of patients with diseases such as Parkinson's disease and dopa-responsive dystonia, L-DOPA, which is the precursor of dopamine, can be given because it can cross the blood-brain barrier.
Sinemet - Parkinsons Disease
Sinemet is made up of levodopa and another drug called carbidopa. Levodopa enters the brain and is converted to dopamine while carbidopa increases its effectiveness and prevents or lessens many of the side effects of levodopa, such as nausea, vomiting, and occasional heart rhythm disturbances. It is generally recommended that patients take Sinemet on an empty stomach, at least ½ hour before, or 1 hour after meals.
****While Sinemet is the most effective medication and has the least short-term side effects, it is associated with high risks of long-term side effects, such as involuntary movements (dyskinesia). Used on a long-term basis, levodopa may also cause restlessness, confusion, or abnormal movements
PET Precautions
Nursing Responsibility
Radiation exposure risk low
Hematoma or infection at site
Preparation
NPO Varies(2-12 hours)
Medications
Caffeine / alcohol / tobacco held
 Special Considerations
 Diabetics
 Takes several hours
Increase water intake after scan
Angiogram
An angiogram is an imaging test that uses x-rays to view your body’s blood vessels. Physicians often use this test to study narrow, blocked, enlarged, or malformed arteries or veins in many parts of your body, including your brain, heart, abdomen, and legs. When the arteries are studied, the test is also called an arteriogram. If the veins are studied, it is called a venogram.
Angiogram Precautions
Usually your physician will ask you not to eat or drink anything within 6 hours of your angiogram. Depending on your particular situation, however, you may be encouraged to take extra fluid before an angiogram. Sometimes this fluid will be given to you by intravenous administration. Also, if you have problems with your kidney functions, you may benefit from medication given to you before the test as well as the extra fluid administration. If you have allergies to the contrast material or to iodine or shellfish, you may require medication before the test to lessen your risk for an allergic reaction. Your vascular surgeon will advise you regarding the best treatment options for your particular situation.