Chronic Neuro Disorders

Which mechanism of action would the nurse identify for levodopa therapy prescribed to a client diagnosed with parkinsons disease

restores the dopamine levels in the brain

Beta Interferons

secreted by fibroblasts, slow inflammation

prodromal period

short period after incubation; early, mild symptoms. The sense the person has that something is wrong. -migraines -more tired -more irritable -funny smell or taste -twitching of muscle

Serotonin receptor agonists "triptans": First-line agents

sumatriptan (lmitrex) xolmitriptan (Zomig)

epileptogenic focus

the area of brain from which the seizure emanates.

which information would the nurse include when teaching a client with parkinsons disease about carbidopa-levodopa

the medication should be taken with meals

postictal phase

the period of time immediately following a tonic-clonic seizure in which the patient goes from full loss of consciousness to full mental status -no further movement -Deep coma like state can occur for a few minutes -remain sleepy for hours -often c/o headache or sore muscles

which adverse response would a nurse assesses for when carbidpoa levodopa is prescribed for a client with parkinsons disease

nausea emotional changes

diagnosis of multiple sclerosis

neurological exam, CSF analysis, cranial CT and MRI scans

immunostilbenes anticonvulsant

oxcarbazepine (trileptal)

which test would the nurse identify as specific for the diagnosis of myasthenia gravis

edophonium chloride test

When should ergotamine be used?

given at first sign of migraine 2nd line drug; used if not responded to triptan

valproic acid patient education

• Report GI SE (abd pain,N/V, anorexia, jaundice) • Report bruising, bleeding • Becoming pregnant NOTrecommended

Valproic acid Precautions

kidney disease. older adults children under the age of 10.

complex partial seizure

level of consciousness is decreased or lost -lasts about 45-90 seconds

serotonin agonists precautions

liver/renal insufficiency

Valproic acid side effects

GI upset, hepatotoxicity, pancreatitis, thrombocytopenia, decreased PLT, Prolonged bleeding time, skin rash, hyperammonemia

adverse effects of phenytoin

Gingival hyperplasia, nystagmus, diplopia and ataxia

Pancreatitis symptoms

Sudden onset LUQ or epigastric pain, vomiting, nausea, Decreased pain with sitting or in fetal position Tenderness and guarding

what must providers asssess for with febrile seizures

meningitis -kids under 12 months sometimes need lumbar puncture to rule this out; dont at any age, if meningitis sx are present

Convulsion

-more serve seizure

Partial seizures

1 area of brain. Most commonly originates in the mesial temporal lobe. Often preceded by seizure aura; can secondarily generalize 1. simple partial onset 2.complex partial onset

Drug treatment of multiple sclerosis

1.Drugs to treat acute symptoms • Glucocorticoids- inflammation and immune response 2.Drugs that modify course of disease("disease modifying") • Beta interferons (e.g. interferon beta &glatiramer acetate (Copaxone) • Naturally occurring proteins in humans• Modify inflammation , alters T cell function, boosts protein synthesis • Reduce exacerbations of MS

multiple sclerosis mostly affects what

20-50 years old

life expectancy for ALS

3-5 years

carbamazepine drug level

4-12 mcg/mL

When given hydantoins: phenytoin (Dilantin) IV what should the nurse do

50 mg/min cardiac monitor

Valproic acid therapeutic range

50-100 mcg/mL

cause of migraines

Changes in serotonin in the brain vasodilation and inflammation of intracranial blood vessels

succinimide

Ethosuximide (Zarontin)

Hepatotoxicity symptoms

Malaise, weakness, lethargy, facial edema, anorexia, vomiting, yellowing of the skin and eyes, jaundice, elevated bilirubin

Transient Ischemic Attack (TIA)

Minor stroke; where neurological function is regained quickly with time

ergot alkaloid SE/AE

N/V, insomnia, visual changes

a client asks the nurse what causes myasthenia gravis. which description of pathology would the nurse use in response to the client asking

a decreased number of functioning acetylcholine receptor sites

embolic stroke

a type of ischemic stroke that causes a clot to travel to the brain, mostly from the left side of the heart

visual aura may precede a migraine.... what is a visual aura?

aura that takes form of brightly flashing lights or rippling images that spread from the corner of the visual field.

Valproic acid CI

avoid in children younger than 3 (hepatotoxicity) liver disorders, pregnancy, high serum ammonia, Low PLT (thrombocytopenia)

absence

brief loss of awareness, repetitive eye blinking for up to 30 seconds, common in kids under 14 y.o

myoclonic

brief muscular jerks but not as extreme as other types

which medication is prescribed to improve the physical manifestations of parkinsons disease

carbidopa-levopdopa

epidermal necrolysis

cell death causes detachment of top layer of skin from the dermis; potentially life-threatening

epilepsy

chronic brain disorder characterized by recurrent seizure activity syndrome of CNS

The nurse teaches a clients family about the administration of donepezil for treatment of dementia of the alzheimer type. which side effect identified by the caregiver indicates to the nurse that further teaching is needed

constipation

goal of anti seizure meds

control seizure but maintain quality of life

amyotrophic lateral sclerosis (ALS)

degenerative disorder of motor neurons in the spinal cord and brainstem

benzodiazepine anticonvulsants

diazepam (valium)

which characteristic would a client who has been taught about myasthenia gravis identify as being common to both myasthenic and cholinergic crises

difficulty breathing

which complication would the nurse assess in both clients who have parkinson disease and clients who have myasthenia gravis

difficulty swallowing

What can happen when an IV dose of is given too quickly hydantoins: phenytoin (Dilantin)

hypotension and dysrhythmias

which problem is in a client presenting to the clinic for a follow-up after starting pyridostigmine for management of myasthenia gravis is an adverse effect of pyridostigmine

increased urinary frequency muscle twitching diarrhea

sleep-deprived EEG

individual deprived of sleep for 24 hours before test. looking for abnormal activity

convulsion characteristic

involuntary spasmodic contraction of any or all voluntary muscle groups

which information would the nurse expect to be reported in the health history of a client with a suspected diagnosis of myasthenia gravis who sees the primary health care provider because of fatigue, double vision, and muscle weakness

muscle weakness improving after a period of rest

clonic

pertaining to alternate contraction and relaxation of muscles

barbiturate anticonvulsant

phenobarbital (solfoton)

which drug is the drug of choice for seizures

phenytoin

used to tx all seizures expect for

phenytoin (dilatin)

atrial fibrillation

rapid, random, ineffective contractions of the atrium quivering and not emptying which is a major reason why emboli is passed

febrile seizures usually manifest as what

tonic-clonic

which symptom of levopda toxicity will a client taking levodopa be taught as a reason to contact the primary health care provider

twitching

thrombotic stroke

type of stroke caused by a blood clot blocking an artery in the brain

atonic

"drop attacks" sudden global muscle weakness and syncope fall down

which instruction will the nurse include when teaching a client with Parkinson's disease who is prescribed carbidopa- levodopa

"you may experience dizziness when moving form sitting to standing"

Aura

(usually just seconds before actual seizure) -beginning of a seizure -odd sensory experience

miscellaneous AEDs

- *Gabapentin (Neurontin)*- neuropathic pain, bipolar disorder. - *Lamotrigine (Lamictal)*- bipolar disorder. Risk for Stevens Johnson syndrome (rash). - *Topiramate (Topamax)* - *Levatiracetam (Keppra)* - *Pregabaline (Lyrica)*- increases action of GABA. Neuropathic pain, fibromyalgia.

multiple sclerosis

-Chronic disease of CNS -myelin sheath destruction. disruptions in nerve impulse conduction

precautions of phenytoin (dilantin)

-DM -Resp dysfunction -liver, renal d/o -monitor carefully in those whose are older -alcoholism, increased risk of toxicity

Serotonin Agonists interventions

-Monitor for any angina s/s -Monitor VS after first dose -Assess those at risk for cardiac issues

Treatment for guillain-barre

-Plasma Exchange (remove circulating antibodies) -IV immune globuln

serotonin agonist patient education

-Same are oral, SC or nasal spray -Use only 1-2/week to avoid medication overuse headache

ALS pathophysiology

-The motor neurons degenerate and die -This ceases communication with skeletal muscle -Without innervation, skeletal muscle atrophies

Multiple Sclerosis Symptoms

-Weakness, numbness, tingling in a limb -Optic neuritis (amaoursis fugax) -Double vision -Loss of balance -Urinary frequency/urgency -Ataxia (lack of voluntary movements) -Hyper-reflexia -Fatigue -Hoffman sign (flicking middle finger causes thumb flexion) -Lhermittes sign (shock sensation down spine on neck flexion)

Symptoms of convulsions

-abnormal motor fx, -loss of consciousness -altered sensory awareness, -psychic changes

tonic clonic

-begins w/ muscle contraction throughout body (tonic phase) and progresses to alternating contraction and relaxation (clonic phase) -positive loss of consciouness -Lasts about 90 sec, or less

side effects of phenytoin (dilantin)

-blunted -more sedated -Gingival hyperplasia (excessive gums, need good oral health) -Rash the may turn into SJS or toxic epidermal necrolysis -Purple glove syndrome -hirsutism -numerous interactions with other meds -pregnancy category D (fetal deformitites)

seizure

-brief episode of abnormal electrical activity in nerve cells of brain; may or may not lead to convulsion

simple partial seizure

-brief loss of awareness -NO loss of consciousness or eye blinking -Can progress to secondary generalized seizures tonic-clonic seizure in up to 40% of pts

serotonin agonists CI

-cardiac history; MI, angina, CAD -PVD -Severe HTN -CVA -Pregnancy

Migraines

-caused by inflammation and dilation of the blood vessels in the cranium. Drugs: beta blockes, anticonvulsants, antidepressants, triptans, NSAIDS/naproxen

serotonin agonists SE/AE

-chest pressure, heavy arm (in about 1/2 of pts) -Transiet; NOT related to ischemic heart disease -NOT dangerous -Angina/coronary vasospasm (rarely) -Assess those at risk and avoid drug in those pts -CNS se (tingling, vertigo)

Seizure diagnosis is based on several things:

-good hisotry, what has been going on with pt? -EEG- Brain wave activity -CT or MRI of brain to r/o structural causes (tumor)

Hydantoins: phenytoin (dilatin) CI

-preg cat: D -Skin rash -bradycardia, heart block -seizures caused by low blood sugar

Nursing interventions re: hydantoins -phenytoin (dilantin)

-pregnancy -blood levels -Skin (rash) -gums -circulation -compliancy

General side/adverse effects of anticonvulsant

-sedation -N/V -Rash, SJS, or TEN (toxic epidermal necrolysis) -Liver issues -Cardiac issues (if given rapid IV push) -bone marrow suppression

Tonic

-spasms of upper trunk, flexion of arms

Anti-seizure drugs: general facts

1. Most anti-epileptic drugs (AEDs) alter NA channels and neurotransmitters (NTs) -increases GABA, restores NT balance -Makes neurons less excitable -Increases seizure threshold -blocks abnormal nerve stimulus 2. AED depends on pt variables and seizure type 3. AEDs are CNS depressants (people are more blunt) 4. sudden withdrawal may precipitate seizures 5. Nursing Implications (take drugs regularly, drug levels, avoid other CNS depressants (alcohol)

symptoms of a stroke

1.weakness, numbness, paralysis of face, arm, or leg on one side of the body 2. blurred vision 3. dizziness 4.sudden, severe headache

therapeutic level of phenytoin

10-20 mcg/mL

status epilepticus

A condition in which seizures recur every few minutes or last more than 15-30 minutes. -most common in gran mal seizures -Airway, ventilation, injury prevention and seizure management important -Loraxepam drug of choice to treat -benzodiazepine increased Gaba -diazepam also used but has shorter half-life

MOA of phenytoin

Alters the movement of sodium, potassium, calcium, and magnesium ions which decreases the discharge of neurons

Valproic Acid (Depakote)

Antiseizure med. Precautions/interactions: contraindicated in liver disease, pregnancy. Side effects: hepatotoxicity, teratogenic effects, pancreatitis.

Actions of triptans

Bind to selective serotonin receptors sites to cause vasoconstriction and prevent inflammation of cranial vessels

symptoms of epilepsy

Can range from momentary sensory disturbances to convulsive seizures most common neuro illness chronic recurrent patterns of seizures

iminostilbenes

Carbamazepine (Tegretol) -AEDs -Also work for bipolar d/o and tigeminal nerve pain -work similarly to hydantoins -inhibit Na influx, decreasing discharge of neuron in high activity areas

secondary epilepsy

Distinct cause identified Trauma, infection, cerebrovascular disorder, tumors

Valproic acid interventions

Do not mix the oral suspension with other oral drug suspensions. Monitor bleeding time, platelet count. Monitor blood ammonia levels. Observe for bruising, bleeding. Watch for vomiting, confusion, decreased level of consciousness. Monitor serum amylase if symptoms of pancreatitis occur. Monitor liver function tests before treatment and periodically during therapy. Observe for symptoms of hepatitis. Ensure that patients take the lowest effective dose.

Primary epilepsy

Epilepsy in which there is no identifiable cause. Also known as idiopathic.

ergotamine

Ergot alkaloid: vascular effect prototype, causes prolonged vasoconstriction, uterine contraction. Used in migraine, obstetrics

Immunomodulators interventions

Nursing: monitor CBC, PLT, liverfunction; acetaminophen or NSAID pre-medfor myalgias and flu-like sx take at HS; teach injection techniques; monitor for mental health changes Fatigue can be so severe thatpatients can be confined to bed

SJS

Prodrome of fever, malaise followed by rapid onset of erythematous/pruritic macules [Oral, ocular, genital]. Skin lesions progress to epidermal necrosis and sloughing

febrile seizures

Seizures that result from sudden high fevers, particularly in children. -common in children 6 months to 5 years of age -usually outgrow this and does not turn into a chronic condition

Types of generalized seizures

absence, myoclonic, tonic-clonic, tonic, atonic

Guillain-Barre Syndrome (GBS)

acute inflammatory disorder that causes rapidly progressing paralysis (which is usually temporary) autoimmune

generalized onset seizure

affects both sides of the brain at the same time -Grey matter in both hemispheres simultaneously involved from onset of seizure

Manifestations of Guillain-Barre

variable and may include weakness, paralysis, paresthesias, pain, and diminished or absent reflexes, starting with the lower extremities and progressing upward; bulbar weakness; cranial nerve symptoms; tachycardia; bradycardia; hypertension; or hypotension

M.S. drugs used to treat sx of the disorder

• Dantrolene, baclophen, diazepam • Anticholinergics for OAB; antidepressants

Common manifestations of multiple sclerosis

• Fatigue is profound and disabling in many pts • Visual issues • Visual loss, diplopia, eye movement disorders • Motor issues • Weakness, spasticity, gait disturbance, coordination problems • Neuro/behavioral • Depression, emotional lability, sexual dysfunction, memory and cognitive deficits; intention tremors; vertigo; paresthesia's • Other • Bladder/bowel difficulties, pain

carbamazeine (tegretol): Iminostilbenes interventions

• Give most of dose atbedtime to avoid CNSeffects • Monitor CBC, WBC and forskin rash • Monitor drug level• ____4-12___________ mcg/mL

risk factors for stroke

• High blood pressure • Atherosclerosis • Heart disease • Smoking or tobacco use • Atrial fibrillation (Afib) • Diabetes • Overweight or Obesity • Blood disorders • Excessive alcohol • Certain medications

classifications of drugs used to treat seizures

• Hydantoins- *phenytoin (Dilantin) • Iminostilbenes • Barbiturates • Benzodiazepines • Succinimides • Miscellaneous Anticonvulsants •phenytoin (Dilantin) •fosphenytoin (Cerebyx)How do they work?

M.s. drugs that interrupt progression of disease

• Immunosuppressants (e.g. methotrexate,cyclophosphamide, mitoxantrone, &cyclophosphamided)

What are issues related to vasoconstriction

• May cause numbness, tingling, or pain in fingers and toes, muscle pain • Contraindicated in any client with vascular disease and in pregnancy (Preg. Cat. X) • Pts can develop physical dependence to drug

patient education: hydantoins, phenytoin (oral )

• NEVER stop taking abruptly • Avoid ETOH (protect liver) • Monitor for toxicities • Soft bristle toothbrush • Regular dental check-ups • Notify provider if rash occurs • Give w/ meals • If drowsy, do not drive, etc.

general nursing interventions re: anticonvulsants

• Seizure precautions when indicated • Advise against driving, operating machinery • Take med at same time each day, as prescribed • Do not crush or chew capsules • Give IV meds slowly; monitor HR and BP if giving IV • Monitor IV site

Carbamazepine se/ae

• Unlike phenytoin, has min. effects on cognitive fx • Nystagmus, ataxia, H/A, blurred vision: usually getbetter with time• Fluid retention......watch who for this - HF, kidney failure? • Hyponatremia: drug promotes secretion of ADH • Skin rash (SJS, epidermal necrolysis) • Bone marrow suppression

Immunomodulators

• interferon beta 1-a (Avonex, Rebif) • beta 1-b (Betaseron) • glatiramer acetate (Copaxone) • natalizumab (Tysabri) • May inhibit movement of leukocytes across blood-brain barrier • Myelin sheath gets damaged when leuks cross this barrier

Beta Interferons AE

• seizures (esp w/ interferon beta -1a) ;• anaphylaxis;• nausea, diarrhea, constipation; • Bone marrow suppression: • leukopenia, neutropenia; fever, chills; • Suicidal ideation • elevated liver enzymes; hepatotoxicity • Myalgias; FATIGUE; flu-like symptoms