Neuro/musculoskeletal By: Diana Blum Msn NURS 2150 Metropolitan Community College

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 Olfactory optic oculomotor trochlear trigeminal abducens facial accessory vestibulocochlear glossopharyngeal vagus hypoglossal I would know the cranial nerves.

Physical assessment Orientation LOC Memory Attention Language/copying 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 Student A try to remember: apple pumpkin lemon bars Student B: count backwards from 100 by 7s

functional Assessment Appearance Speech Motor function Family history Ethnicity Diet ADLs Right handed or left handed Brain injury is more pronounced in dominant hemisphere What would be concerning with speech or appearance? Slurred Disheveled Wearing to many layers for a given season

Sensory assessment Pain and temp Touch 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 The cotton ball is soft and fluffy which looks at light touch or sensation Whereas paperclips are sharp and wherever you poke it it should be felt

Motor assessment Hand grasps Foot strength Arm drift Coordination Gait Balance Reflexes ABNORMAL FINDINGS tremors, weakness, paralysis, jerking muscles Why are these important? What do they tell us? stroke..drunk etc How do you measure arm drift? What do you do with abnormal findings..call the md.

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 Mental Status Does not decline with age Caused by drugs or lack of o2 to the brain As we age LTM is better then STM Pg. 491 glascow coma scale is most widely used for measuring loc in Traumatic Brain Injury eye opening verbal response motor response Certain conditions may alter the results: ETOH shock drugs metabolic issues

20-3 in book

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

Fully alert and oriented Comatose 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 A score of 7 or less indicates a comatose client. Above that are varying degrees of consciousness. Coma: No eye opening, no ability to follow commands, no word verbalizations (3-8) Student A what were you asked to remember? Apple pumpkin lemon bars

That was review from nurs 2520 and A&P This is testable material.. So read CHAPTER 20

Seizures/Epilepsy Seizure: 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 Pg. 543 Not all seizures cause convulsions some do.

Tonic is where the muscles contract and relax Clonic is more rhythmic jerking

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 General seizures affect whole body. Petit mal aka absence seizures last 15 seconds…..staring spell most common is kids 6-12 yrs old Grand mal aka tonic clonic affects entire body….associated with epilepsy….aura may be present. Post ictal phase they get limp Simple partial doesn’t affect memory Complex partial does affect memory See chart 21-5 Types of Seizures

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 Fever from infection or unknown cause is a culprit esp. in kids Meds that may help is dilantin: used for grand mal epilepsy / it slows impulses down check cbcs Tegretol: works as anticonvulsant for conditions like epilepsy and trigeminal neuralgia

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

Nerve cells transmit signals to and from the brain in two ways by 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. At the end, a neurotransmitter is released, which carries the impulse to the next nerve cell. Neurotransmitters either slow down or stop cell-to-cell communication (called inhibitory neurotransmitters) or stimulate this process (called excitatory neurotransmitters). Normally, nerve transmission in the brain occurs in an orderly way, allowing a smooth flow of electrical activity. Improper concentration of salts within the cell and overactivity of either type of neurotransmitter can disrupt orderly nerve cell transmission and trigger seizure activity.

Types of Epilepsy Primary or idopathic Secondary Status epilepticus 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 Types of Epilepsy

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 See page 544

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 Diagnostics: EEG CT MRI PET

TREATMENT Nonsurgical Teach family 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 See seizure management on page953 DO not insert tongue blade Document duration movements change in pupil size activity before, etc Priority is to protect from injury and the airway o2, diazepam, turn head to side Think AVPU: awake and alert verbal stimuli painful stimuli unresponsive Remain calm pillow under head Cant drive for 6 months after seizure and no further seizures in same timespan

Surgical treatment Vagal nerve stimulation Corpuscalostomy 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 diagnosis Risk for falls Ineffective coping Risk for ineffective breathing

HUNTINGTON’S DISEASE Formerly 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

classes Generalized:involves many structures Regional: limb involved 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 prevention Teach about exercise Teach about diet rich in calcium Teach about bone health Teach about safety

Assessment Risk for falls Head to toe assessment Assess pain Inspect and palpate vertebrae Assess pain Assess for fallophobia No definitive lab tests Bone scan to check density

Nursing diagnosis Risk for falls Impaired physical mobility Acute or chronic pain

Interventions Client 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 The most common fractures are called transverse fractures

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 What is a good nursing dx? Impaired physical mobility

Diagnostics Serum alk phosphate Urine hydroxyproline 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 Sequestrium is a piece of dead bone that separates during necrosis.

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 Wound cultures are vital to id the organism

s/s and assessment Pain 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 Joint pain is common and tends to be worse at nites Dx ct is preferred but can bx

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 They can do a minimal invasice tx where special cement is injected into tumor

Malignant bone tumors Primary: 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 Wings is a round cell tumor found in bones and soft tissue Most common pelvis femur humerous ribs Most in male teens Tx: chemo first, radiation, amputaion

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 Occurs when the median nerve becomes pressed or squeezed at the wrist. Swelling is one thing that can cause compression Symptoms start gradual and work to frequent burning tingling itchy, numb There are a number of causes like fx, sprains, overactive pituitary, etc Women get more than men

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 Ergonomics are important

Dupuytren’s contractures Slow progressive contracture Common problem Affects 4th or 5th digit of the hand Trigger finger release surgery performed to fix Stuck trigger finger. To fix tendon release

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

Vertigo 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

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. What are migraines They are believed to be caused by dilation of cranial arteries. They can be debilitating. Dark rooms, sleep can help What are some triggers? Cheese, ETOH, caffeine, Chocolate, Aged Meat, Soy beans, nuts, yeast, sauerkraut, Red wine= the worst

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 headache Muscle 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 Stress is the main culprit

Parkinson’s http://www.youtube.com/watch?v=TtM-aP9Gr28 pg 605 Pill rolling and suffling gait are signs Thicken fluids Allow them time to ready themselves Bradykinesia= diff walking

Alzheimer’s Disease http://www.youtube.com/watch?v=Z6lA1P2tF0o&feature=related Pg 590

Stages Early Middle Late mild moderate severe Stages are 1-7 1 is no memory probs 2 is very mild decline 3 mild decline 4 moderate decline 5 moderately sever decline 6 severe decline: personality changes sleep issues, incontinence 7 very severe decline cant sit , walk, talk

s/s Aggressive Rapid mood swings Increased confusion at nite (sundowner’s) Decrease interest in personal appearance Inappropriate clothing selection Loss of bowel/bladder Decreased appetite Think sundowners

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 diagnosis Chronic 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 Aricept is a big one improves function of nerve cells in the brain it prevents breakdown of acetylcholine Communicate in simple words with calm tone Promote recognition with fam photos Reorient with labels on things distractions fall precautions

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

Nutrition 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

glaucoma 2 types Primary open angle: most common Angle closure: less common..emergency Damage is to optic nerve that carries visual info to brain

s/s Open angle: small cresent shaped defect Angle closure: visual fields quickly decrease, severe pain around eye, headache, n/v, halos, blurred vision Pg 2333? Angle closure is medical emergency blind in few days Gtts and surg to tx Goal reduce pressure Symptoms come and go at first

Macular degeneration Central vision declines Mild blurring or distortion More rapid to produce in smokers Damage to central vision

Spinal Cord Injury (SCI) Chapter 24 Spinal Cord Injury (SCI)

Causes of SCI Hyperflexion (moved forward excessively) Primary 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

Complete Tetraplegia (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*

Incomplete Central Cord Syndrome Anterior 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

Incomplete Posterior cord lesion Brown Sequard syndrome 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

Assessment C4-5 apply downward pressure while the client shrugs 1st -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 Know your posturing- decorticate vs decerebrate

Complications Cerebral ischemia DVT/PE Pneumonia/Atelectasis Vomiting and Aspiration GI stress ulcers Constipation UTI Pressure Ulcers

Autonomic Dysreflexia Severe 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

Treatment Immobilize fx- C-collar Proper body alignment Traction is possible Monitor VS q4 hr and prn Neuro checks q4 hr and prn Monitor for neurogenic shock (hypotension and bradycardia) Prepare for possible surgery Teach 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 Injuries Common Abrasions “Goose Eggs” Lacerations Scalp is very vascular Xray if suspect skull fracture A complication of head injury is DI which happens because the hypothalamus or posterior pituitary gets injured remember this is when they pee out >9 Liters /24 hours. DDAVP is the drug tx

Skull Fractures Categorized 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 What symptom do you think would be alarming? letharg

Open Skull Fractures Linear- 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 Fractures Closed- 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) If you see clear liquid draining from ears or nose what do you think? CSF What do you do? Check for dextrose look for halo

Intracranial Hematomas Epidural- 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 Along with hematomas is hemorrhages that can occur. Which are discussed in chapter 22. seizures can occur from them along with hyponatremia. Salt wasting can occur due to trauma or tumor. Once salt levels get to around 120 or lower seizures can occur. (pg. 575).

Increased Intracranial Pressure (ICP) Pg 568 Increased Intracranial Pressure (ICP)

Drivers of increased ICP 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 ICP Normal 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 continued 3 types of edema Vasogenic: increase in brain tissue volume Cytotoxic: result of hypoxia Interstitial: occurs with brain swelling

Assessment s/s of a problem: altered LOC usually first, restless, unequal pupils, coma, death, comitting, increased sbp decreased hr irregular respiration Goal of management is to prevent secondary injury Tx:mannitol, hyperosmol fluids and those listed here. Mannitol is used in acute situations only.. It is caustic to the body causing heart issues, RF etc.

Hydrocephalus abnormal increase in CSF volume Causes: impaired reabsorption from subarachnoid hemorrhage or menengitis Pg. 575 Found from ct scan.. Treatment is a shunt

Brain Herniation Increased 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 Dilated, nonreactive pupils, ptosis, rapidly decreased LOC Pg 568

Herniation syndromes.

Movement/musculoskeletal

Rheumatoid Arthritis Pg 1836-47

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 Heat relaxes muscles but cold therapy reduces swelling Swimming is good for jevenile type Gouty arth is from uric crystals depositing usually in big toe Tx avoid pruine foods

Gout Type 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 Drugs are allopurinol and cholchinine SE of diarrhea

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 distrophies 9 types Progression is slow or fast Most common is severe X linked recessive Diagnosis is difficult Comfort is key Treat symptoms Characterized by progressive weakness and degeneration of muscles that control movement Duchenne is most common and more in boys Myotonic is most common adult Tx symptoms---steroids anticonvulsants antibx, immunosuppresants, vents ALS dx of nerves aka lou gerhigs: diff breathing swallowing head drop paralysis…no cure Tx riluzole helps prolong life pt ot speech vent MS damaged myelin sheaths most common in young women no cure Diff to dx Tx steroids interferon rehab medical cannibus, hyperbaric oxygen

AMPUTATION REVIEW

amputations Removal of part of the body Types Levels Complications 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

TIPS!! Review Meds on 599-604 Review cranial nerves