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Neuro 1

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primary brain tumors

-localized intracranial lesions -may be malignant OR benign -RARELY spread -Symptoms: seizures, increased ICP Surgery (best outcome), radiation, chemo, drugs

Clinical Manifestations: HALLMARK TRAP Tremor Rigidity Akinesia/Bradykinesia (w/out or decreased body movement) Postural Disturbances

GBS

Nursing Interventions for Enhancing Physical Mobility: • Support the paralyzed extremities in a functional position, and perform passive range-of-motion exercises at least twice daily. • Pad bony prominences and change patient's position at least every 2 hours. • Administer prescribed anticoagulant regimen to prevent DVT and PE; provide anti embolism stockings or sequential compression boots, as well as adequate hydration.

diskinesia

impaired ability to execute voluntary movements

Autonomic Dysreflexia

(potentially life threatening emergency!) HOB elevate 90 degrees, loosen constrictive clothing, assess for full bladder or bowel impaction, (trigger) administer antihypertensives (may cause stroke, MI, seizure)

Parkinson's disease

-(PD) is a slowly progressing, degenerative neurologic movement disorder that eventually leads to disability. -decreased levels of dopamine resulting from destruction of pigmented neuronal cells in the substantia nigra in the basal ganglia of the brain. -The loss of dopamine stores in this area of the brain results in more excitatory -neurotransmitters than inhibitory neurotransmitters, leading to an imbalance that affects voluntary movement. -Cellular degeneration causes impairment of the extrapyramidal tracts that control semiautomatic functions and coordinated movements;

Gliomas

-Glioblastoma multiforma (GBM is most common and aggressive MALIGNANT brain tumor -grow rapidly and are highly malignant; blood-brain barrier decreases effectiveness of chemotherapy; treatment consists of radiation or surgery

amyotrophic lateral sclerosis (ALS)

-Lou Gehrig's disease, is a degenerative disease characterized by loss of upper and lower motor neurons -As the motor neurons die, the muscle fibers that they supply undergo atrophic changes. -ALS include autoimmune disease, glutamate excitotoxicity, free radical injury, axonal strangulation, mitochondrial dysfunction, and oxidative stress.

Spinal Cord Compression

-MEDICAL EMERGENCY!!! Clinical Manifestations: -Pain -loss of reflexes ABOVE the tumor level -loss of sensation or motor function -weakness -paralysis

Meningiomas

-MOST COMMON BRAIN TUMOR -slow growing and benign

-This results in voluntary muscle weakness that escalates with continued activity. -MOTOR DISORDER ONLY

brain angiomas

-abnormal blood vessels that are found in the brain or on its surface

pituitary tumors

-abnormal growths that develop in the pituitary gland -nonfunctioning-does not secrete hormones or -functioning-over secretion of hormones

Acoustic Neuroma

-benign tumor on the auditory nerve (8th cranial nerve) that causes vertigo, tinnitus, and hearing loss -corrected surgically

Bell's palsy

-causes unilateral facial paralysis due to peripheral involvement of the seventh cranial nerve (FACIAL NERVE), which results in weakness or paralysis of the facial muscles on the ipsilateral side. -vascular ischemia, viral disease (herpes simplex, herpes zoster), autoimmune disease, or a combination of all of these factors. -The inflamed, edematous nerve becomes compressed to the point of damage, or its blood supply is occluded, producing ischemic chemic NECROSIS OF THE NERVE

Guillian-Barre Syndrome (GBS)

-is an autoimmune attack on the peripheral nerve myelin, producing ascending weakness and dyskinesia. -result of a cell-mediated and humoral immune attack on peripheral nerve myelin proteins that causes inflammatory demyelination. -Symptoms usually occur/develop about 2 weeks after an acute viral infection or immunization. -The result is acute, rapid segmental demyelination of peripheral nerves and some cranial nerves, producing ascending weakness, dyskinesia, hyporeflexia, and paresthesia. -the Schwann cell that produces myelin is spared, allowing for remyelination in the recovery phase of the disease.

myastehnia gravis (MG)

-is an autoimmune disorder affecting the acetylcholine receptors of the myoneural junction. -antibodies reduce the number of acetylcholine receptor sites, impairing transmission of impulses across the neuromuscular junction. -This results in voluntary muscle weakness that escalates with continued activity. -Hyperplasia and tumors of the thymus are frequently found in MG patients.

C. back pain. The nurse is aware that an early patient complaint of back pain occurring in the region of the tumor and that typically increases in the prone position is an early symptom of SCC.

1. A patient admitted to the emergency room has a history of a spinal tumor. Which of the following signs and symptoms should alert the nurse to the possibility of SCC? Seizures Headache Back pain Diplopia

A. The patient is instructed to remain immobile during the angiogram process and is told to expect a brief feeling of warmth I the face, behind the eyes, or in the jaw, teeth, tongue, and lips, and a metallic taste when the contrast agent is injected. The patient is instructed to void before going to the x-ray department. The patient should be well hydrated, and clear liquids are usually permitted up to the time of a regular arteriogram. After the groin is shaved and prepared, a local anesthetic is administered to prevent pain at the insertion site of the catheter and to reduce arterial spasm.

1. A patient is undergoing a cerebral angiography to rule out an aneurysm. When preparing the patient for the procedure, the nurse would include which of the following in her instructions? Expect a metallic taste when the contrast agent is injected. You will need a full bladder prior to the procedure. Maintain an NPO status. General sedation will be given prior to procedure.

A. Common complications following a lumbar puncture include: Post-lumbar puncture headache, voiding difficulties, slight elevation of temperature, backache or spasms, and stiffness of neck. Rare complications include: Herniation of intracranial contents, spinal epidural abscess, spinal epidural hematoma, and meningitis.

2. The nurse is assisting with a lumbar puncture. The nurse understands that which of the following common complications can occur following the procedure? Post-lumbar puncture headache Herniation of intracranial contents Spinal epidural abscess Meningitis

D. To increase the chances of recording seizure activity, it is sometimes recommended that the patient be deprived of sleep on the night before the EEG. Antiseizure agents, tranquilizers, stimulants, and depressants should be withheld 24 to 48 hours before an EEG because these medications can alter the EEG wave patterns or mask the abnormal wave patterns of seizure disorders. The patient is reassured that the procedure does not cause an electric shock.

3. A patient is scheduled for an EEG tomorrow. Which of the following information should the nurse provide to the patient prior to the procedure? Antiseizure medications need to be taken prior to procedure. Sedation will be given during the procedure. There is a slight chance of electric shock. Maintain a sleep-deprived state the night before procedure.

A, B, D. movement of upper and lowerextremeties, monitoring sensation, strength assessment. Bowel function is important but is not a priority 8 hours after surgery and is not part of the neurologic exam.

4. A nurse is caring for a patient who is 8 hours post surgery for a spinal cord tumor. Neurologic checks should include which of the following? Select all that apply. Movement of upper and lower extremities Monitoring sensation Bowel and bladder function Strength assessment

B. A lack of the neurotransmitter dopamine leads to Parkinson's disease. Lack of actylcholine, serotonin, and GABA do not lead to the development of Parkinson's disease.

4. A patient with Parkinson's disease is seen in the neurology clinic for treatment. The nurse identifies this disorder as being caused by a lack of which of the following neurotransmitters? Acetylcholine Dopamine Serotonin Gamma-aminobutyric acid (GABA)

B. ionizing radiation. Ionizing radiation and cancer-causing chemicals are the only proven causes of brain tumors. Other possible causes include non-ionizing radiation, acoustic trauma, and dietary factors. Genetic syndromes are also under investigation.

5. A patient has just been admitted to the hospital with a diagnosis of brain tumor. She makes a comment that drinking alcohol has caused her brain tumor. The nurse understands that which of the following is a cause of brain tumor? Smoking Ionizing radiation Diet high in fat Exposure to the sun

B. To assess chewing, the patient is asked to clench his jaw while the nurse palpates the temporal and master muscles. This tests the trigeminal nerve which is cranial nerve V. The abducens nerve is tested with EOMs. The acoustic nerve tests hearing. When assessing tongue movement, the nurse is testing cranial nerve XII or the hypoglossal nerve.

5. The nurse is testing the cranial nerves of a patient diagnosed with myasthenia gravis. The nurse asks the patient to clench his jaw while she palpates the temporal and masseter muscles. The nurse is correctly testing which cranial nerve? Abducens Trigeminal Acoustic Hypoglossal

ineffective airway clearance r/to brain injury

A client has sustained a traumatic brain injury. Which of the following is the priority nursing diagnosis for this client?

understanding language, emotion and memory

A client is diagnosed with a tumor of the temporal lobe. When developing the client's plan of care the nurse would plan interventions to address problems with which areas of functioning?

D. Ninety percent of GB patients get better, but the recovery is very slow, over 1 to 2 years. Motor strength does not improve each day; it occurs over months of recovery. "Providing the best care" does not really answer the patient's question about getting better. Asking the patient what they think is not an appropriate response in this situation.

A client who has GB asks, "Will I ever get better?" Which of the following responses would be the most appropriate answer by the nurse? "You'll notice your strength will improve each day." "We are doing everything we can to provide the best care." "You seem concerned about getting better. What do you think?" "Your chances for recovery are very good but recovery is slow."

A client who has GB asks, "Will I ever get better?" Which of the following responses would be the most appropriate answer by the nurse? A. "You'll notice your strength will improve each day." B. "We are doing everything we can to provide the best care." C."You seem concerned about getting better. What do you think?" D. "Your chances for recovery are very good but recovery is slow."

risk for injury

A client who is disoriented and restless after sustaining a concussion during a car accident is admitted to the hospital. Which nursing diagnosis takes the highest priority in this client's care plan?

Lung auscultation and measurement of vital capacity and tidal volume

A client with weakness and tingling in both legs is admitted to the medical-surgical unit with a tentative diagnosis of Guillain-Barré syndrome. On admission, which assessment is most important for this client?

flaccidity

A nurse is caring for a client with deteriorating neurologic status. The nurse is performing an assessment at the beginning of the shift that reveals a falling blood pressure and heart rate, and the client makes no motor response to stimuli. Which documentation of neuromuscular status is most appropriate?

blurry vision, pain when moving the eyes and dark spots

A patient is suspected of having multiple sclerosis. The neurologist orders various test. The patient's MRI results are back and show lesions on the cerebellum and optic nerve. What signs and symptoms below would correlate with this MRI finding in a patient with multiple sclerosis?

WBCs (decreases), and liver enzymes

A patient w/ MG who is receiving cytotoxic (inhibits T lymphocytes) needs to have what labs monitored?

Tetrabenazine (Xenazine)

A patient with Huntington's disease is prescribed medication to reduce the chorea. What medication will the nurse administer that is the only drug approved for the treatment of this symptom?

D. side lying. The patient should be placed in a side-lying position to decrease the risk of aspiration. Suction equipment should also be at the bedside.

A patient with a decreased level of consciousness and an absent gag reflex was just admitted to the neurologic unit. In what position should the nurse place the patient? Prone Head of bed should be elevated 45-90 degrees Flat Side lying with head of bed elevated 10-30 degrees

cholinergic crisis

A problem of overmedication; overmedication; it results in severe generalized muscle weakness, respiratory impairment, and excessive pulmonary secretions that may cause respiratory failure. Have atropine on hand for treatment.

A score of ....or lower usually indicates coma. The total score will range from 3 to 15; the higher the number, the better.

A score of....on Glascow Coma Scale indicates severe impairment of neurologic function, brain death, or pharmacologic inhibition of the neurologic response.

motor cortex

A tumor in the ..... of the frontal lobe produces hemiparesis and partial seizures on the opposite side of the body or generalized seizures.

A vital capacity of ......mL/kg indicates a need for mechanical ventilation.

Cranial Nerve VI

Abducens

Autonomic dysreflexia can occur with spinal cord injuries above which of the following levels?

hemorrhagic stroke

Brain angiomas (masses composed largely of abnormal blood vessels) are found either in the brain or on its surface. Because the walls of the blood vessels in angiomas are thin, affected clients are at risk for

vagus nerve CN X

CN that controls the gag reflex and is tested by depressing the posterior tongue with a tongue blade. An absent gag reflex is a significant finding, indicating dysfunction of this nerve.

Autonomic Dysreflexia

Characteristics of this acute emergency are as follows: severe hypertension; slow heart rate; pounding headache; nausea; blurred vision; flushed skin; sweating; goosebumps (erection of pilomotor muscles in the skin); nasal stuffiness; and anxiety.

GBS

Clinical Manifestations: -Begins w/ muscle weakness and diminished reflexes in the lower extremities -Hyporeflexia and weakness may progress to tetraplegia. ****-neuromuscular respiratory failure (Demyelination of the nerves that innervate the diaphragm and intercostal muscles) • Sensory symptoms include paresthesias of the hands and feet and pain • Cranial nerve demyelination can result in a variety of clinical manifestations. • Optic nerve demyelination may result in blindness. • Bulbar muscle weakness related to demyelination of the glossopharyngeal and vagus nerves results in the inability to swallow or clear secretions. • Vagus nerve demyelination results in autonomic dysfunction, causing instability of the cardiovascular system manifested by tachycardia, bradycardia, hypertension, or orthostatic hypotension. .

Clinical Manifestations: -Ocular Muscles (diplopia and ptosis/drooping of upper eyelid) Generalized Weakness: face=bland facial expression -throat w/ bulbar symptoms (altered voice, nasal regurgitation, choking, dysphagia) -Laryngeal Involvement: Dysphonia (voice impairment) INCREASED RISK OF CHOKING AND ASPIRATION • Generalized weakness that affects all extremities and the intercostal muscles, resulting in decreasing vital capacity and respiratory failure

Clinical Manifestations: -tremor, rigidity, Akinesia/Bradykinesia, postural disturbances • Resting tremors that disappear with purposeful movement are a slow, unilateral turning of the forearm and hand (pronation-supination) -pill-rolling motion of the thumb against the fingers; tremor increases with walking, concentration, and anxiety. • Rigidity characterized by resistance to passive limb movement • Involuntary stiffness of passive extremity increases when another extremity is engaged in voluntary active movement. • Akinesia, a lack of movement, and bradykinesia, a slowness of initiation and execution of movement occur. • Loss of postural reflexes: The patient stands with the head bent forward and walks with a propulsive gait. The patient may walk faster and faster, trying to move the feet forward under the body's center of gravity (shuffling gait).

ALS

Clinical Manifestations: Depend on the location of affected motor neurons -fatigue, asymmetric, progressive muscle weakness, spasticity, and overactive deep tendon stretch reflexes. -Cranial Nerves: • Soft palate and upper esophageal weakness, causing liquids to be regurgitated through nose; weakness of posterior tongue and palate impair ability to laugh, cough, or blow nose -Bulbar Impairment: difficulty in speaking and swallowing, nasal voice, unintelligible speech, and emotional lability develops. -Intellectual function REMAINS INTACT • Eventually, aspiration, infection, and compromised respiratory function lead to death.

Brain Tumors

Clinical Manifestations: Increased ICP Headache Personality changes fatigue nausea w/ or w/ out vomiting seizures papilledema motor, sensory, and cranial nerve dysfunction hemiparesis Cushing's triad (late symptom)

Bell's Palsy

Clinical Manifestations: • Facial distortion from paralysis; when asked to smile, weakness of the involved nerve will be noted, there will be an absence of wrinkling on the forehead, the affected side will appear mask-like. • Increased lacrimation • Pain in face, behind the ear, and in the eye of the affected side • Ear pain may precede paralysis by 24 to 48 hours. • Speech difficulties and inability to eat on affected side • Disturbance of taste

GBS

Complications: -Respiratory Failure -Cardiac arrhythmias -transient HTN -DVT/PE -urinary retention ****Patient is most likely IMMOBILE, and ventilated***

Complications: • Cholinergic crisis: A problem of overmedication; overmedication; it results in severe generalized muscle weakness, respiratory impairment, and excessive pulmonary secretions that may cause respiratory failure. Have atropine on hand for treatment. • Myasthenic crisis: Most commonly precipitated by respiratory infection; it is a sudden, temporary exacerbation of the disease process. Respiratory distress and varying degrees of dysphagia (difficulty swallowing), dysarthria (difficulty speaking), eyelid ptosis, diplopia, and prominent muscle weakness occur:

Complications: • Respiratory and urinary tract infections • Skin breakdown • Injury from falls

CN II Optic Nerve

Cranial nerve that is affected with decreased visual fields and acuity.

Diagnostics: -2/4 Of TRAP -patient hx • Medical history, presenting symptoms, neurologic examination, and response to pharmacologic management are carefully evaluated when making the diagnosis.

ALS

Diagnostics: -Based on Signs and Symptoms -NO specific tests -Electromyographic (EMG) and muscle biopsy studies, MRI, and neuropsychological testing may be helpful.

Brain Tumor

Diagnostics: -MRI (gold standard) -CT -PET -Cytologic studies of CSF

Diagnostics: • An acetylcholinesterase test using an injection of edrophonium (Tensilon) is used to confirm the diagnosis. Immediate improvement in muscle strength represents a positive test and usually confirms the diagnosis. • Acetylcholine receptor antibodies are identified in serum. • Computed tomography (CT) scan of the mediastinum is performed to detect thymoma or hyperplasia of the thymus. • Repetitive nerve stimulation demonstrates a decrease in successive action potentials.

GBS

Diagnostics: • Decreased vital capacity and negative inspiratory force are assessed to identify impending neuromuscular respiratory failure. • Elevated protein levels are detected in cerebrospinal fluid (CSF) evaluation, without an increase in other cells. • Evoked potential studies demonstrate a progressive loss of nerve conduction velocity.

Parkinson's

Early signs include stiffness, referred to as rigidity, and tremors of one or both hands, described as pill-rolling (a rhythmic motion of the thumb against the fingers). The hand tremor is obvious at rest and typically decreases when movement is voluntary, such as picking up an object. Bradykinesia, slowness in performing spontaneous movements, develops. Clients have a masklike expression, stooped posture, hypophonia (low volume of speech), and difficulty swallowing saliva. Weight loss occurs. A shuffling gait is apparent, and the client has difficulty turning or redirecting forward motion. Arms are rigid while walking.

Battle's Sign

Edema to the head with bruising of the mastoid process

eyes

First part of body to be affected by MG?

Hallmark: muscle weakness gets worse with activity (especially repetitive activity) but will improve after resting the muscle

Cushing's Triad

Late/Ominous Symptom: Hypertension Wide pulse pressure bradycardia respiratory depression

Nero Autoimmune Disorders

MG, MS, GB

A patient has a lumbar puncture that shows proteins in the CSF, what disease process is this r/to?

Uhtoff's sign

MS: is where when the patient experiences too much heat their symptoms increase and get worst. Therefore, it is important the patient stays cool and doesn't overheat (overheating can come from outside temperatures, exercise, emotional events etc.). The room should be cool and the patient should be encouraged to exercise but to avoid overheating.

Medical Management: -Plasmapheresis or plasma exchange (temporary reduction in the titer of circulating antibodies during acute exacerbations; improvement may only last a few weeks) Surgery: -Thymectomy can produce antigen-specific immunosuppression and produces improvement in almost all patients; it may take months before benefits are demonstrated.

Medical Management: -controlling symptoms and maintaining functional independence. Medication: -Levodopa (converted to dopamine) Benefits wane over time (s/e over time: confusion, hallucinations, depression, sleep alterations) -Carbidopa w/ Levidopa (amino acid decarboxylase inhibitors) • Anticholinergic agents, trihexyphenidyl HCL or benztropine, control tremor. • Amantadine hydrochloride (Symmetrel), an antiviral agent, reduces akinesia and tremor. • Dopamine agonists (eg, pergolide [Permax], bromocriptine mesylate [Parlodel]), ropinirole (Requip), and pramipexole (Mirapex) are used to postpone the initiation of carbidopa and levodopa therapy or added when carbidopa/levodopa loses effectiveness. • Monoamine oxidase inhibitors (MAOIs) selegiline (Eldepryl), rasagiline (Azilect) • Zydis selegiline HCl (Zelapar) used with a dopamine agonist to delay the use of carbidopa or levodopa therapy. • Catechol-O-methyltransferase (COMT) inhibitors, entacapone (Comtan) and tolcapone (Tasmar), in combination with carbidopa or levodopa, can increase the duration of action. • Antidepressant drugs including tricyclics, selective serotonin reuptake inhibitors (SSRIs), and atypical antidepressants.

Medical Management: -improving function and reducing and removing circulating antibodies that are attacking the muscle/receptors and causing the weakness Medications: • Acetylcholinesterase medications with pyridostigmine bromide (Mestinon) (increases concentration of acetylcholine at the neuromuscular junction and is first line of therapy.) • Immunosuppressant agents are used if pyridostigmine bromide does not improve symptoms: -Corticosteroids (prednisone) Suppresses immune response and antibodies (ocular symptoms) • Cytotoxic medications such as azathioprine (Imuran), an immunosuppressive drug, are used when response to steroids is inadequate. Azathioprine inhibits T lymphocytes and reduces acetylcholine receptor antibody levels; therapeutic effects may not be evident for 3 to 12 months. Leukopenia and hepatotoxicity are serious adverse effects; monthly evaluation of liver enzymes and white blood cell count is necessary. • Intravenous immune globulin (IVIG) treatment involves the administration of pooled human gamma globulin, which usually produces (quick BUT short relief) .

Bell's Palsy

Medical Management: -to maintain facial muscle tone and to prevent or minimize denervation. Medication: • Corticosteroid therapy (prednisone) Reduce inflammation and edema, reduce vascular compression (restores blood circulation to the facial nerve) EARLY ADMINISTRATION -Analgesics w/ heat (facial pain) -Electrical Stimulation (Preven muscle atrophy)

GBS

Medical Management: MEDICAL EMERGENCY (rapid progression to respiratory failure) -Respiratory Support w/ mechanical ventilation -Elective intubation (prior to extreme respiratory muscle fatigue) • Complications of immobility are prevented with anticoagulants and antiembolism stockings, or sequential compression boots may be used to prevent thrombosis and pulmonary emboli (PE).

GBS

Medical Management: Medication: • Plasmapheresis and IV immunoglobulin (IVIG) are used to decrease antibody levels and reduce time of immobilization; IVIG is associated with fewer side effects. • Labile autonomic dysfunction requires continuous ECG monitoring to detect tachycardia. Tachycardia and hypertension are treated with short-acting medications such as alpha-adrenergic blocking agents. Treat the cardiac instability • Hypotension is managed by increasing the amount of IV fluid administered.

ALS

Medical Management: NO CURE (home/hospital management of Acute problems) Medications: • Riluzole (Rilutek), a glutamate antagonist, may have a neuroprotective effect in early stages. • Baclofen, dantrolene sodium, or diazepam is given for spasticity.

ALS

Medical Management: NO CURE (home/hospital management of Acute problems) • Enteral feedings via percutaneous endoscopic gastrostomy (PEG) tube • Noninvasive positive-pressure ventilation or tracheostomy with invasive ventilation • Decision about life support measures is based on patient's and family's understanding of the disease, prognosis, and implications of initiating such therapy. • Encourage patient to complete an advance directive or "living will" to preserve autonomy.

Medical Management: Surgical Management: -Deep brain stimulation is used to deliver high-frequency electrical stimulation to the thalamus; a pulse generator implanted in a subcutaneous subclavicular or abdominal pouch delivers electrical impulses to a lead anchored to the skull. The electrode blocks nerve pathways in the brain that cause tremors. • Progressive exercise program increases muscle strength, improves coordination and dexterity, reduces muscular rigidity, and prevents contractures of unused muscles. -Assistive and Adaptive devices -Bowel Regimen

Medication Problem: • On-off syndrome in response to the medication causes sudden periods of near-immobility ("off effect"), followed by a sudden return of effectiveness of the medication ("on effect").

osteosarcoma

Most common and most fatal bone tumor that spreads to the lungs

myasthenia crisis

Most commonly precipitated by respiratory infection; it is a sudden, temporary exacerbation of the disease process. Respiratory distress and varying degrees of dysphagia (difficulty swallowing), dysarthria (difficulty speaking), eyelid ptosis, diplopia, and prominent muscle weakness

GBS

NURSING PRIORITY ASSESSMENT: Respiratory Failure: -breathlessness (when taking shallow and irregular breaths) -use of accessory muscles -tachycardia -weak cough -changes in breathing patter

NURSING PRIORITY: AIRWAY!!! Due to: -Laryngeal Involvement: Dysphonia (voice impairment) INCREASED RISK OF CHOKING AND ASPIRATION

70 to 100

Normal cerebral perfusion pressure (CPP)

GBS

Nursing Diagnoses: • Impaired gas exchange • Risk for aspiration • Risk for anxiety and social isolation • Impaired mobility • Risk for altered nutrition less than body requirement • Impaired communication

Nursing Interventions (mostly outpatient): -MEDICATIONS NEED TO MAINTAIN STABLE BLOOD LEVELS FOR BEST EFFECT (maintain muscle strength and prevent respiratory muscle weakness....AIRWAY) • Teach patients about the actions of medications and need to take them on schedule; teach patients that delaying medications may produce signs and symptoms of myasthenic crisis. • Teach patients symptoms of cholinergic crisis. A diary can help identify fluctuation and symptoms to determine best times for medication dosing. • Mealtimes should coincide with peak effects of anticholinesterase medication; rest prior to meals will reduce muscle fatigue.

Nursing Interventions Preventing Choking/Aspiration: • Advise patient to sit upright during meals, with the neck slightly flexed to facilitate swallowing. • Soft foods in gravy or sauces can be swallowed more easily; if choking occurs frequently, suggest puréed food with a pudding-like consistency. • Ensure suction is available at home and that the patient and family are instructed in its use.

GBS

Nursing Interventions for Improving Communication: • Establish communication through lip reading, use of picture cards, or eye blinking. • Collaborate with speech therapist, as indicated.

GBS

Nursing Interventions for Maintaining Respiratory Function • Encourage use of incentive spirometry and provide chest physiotherapy. • Monitor for changes in vital capacity and negative inspiratory force; vital capacity of less than 15 mL/kg indicates need for mechanical ventilation. • Suction to maintain a clear airway.

GBS

Nursing Interventions for Providing Adequate Nutrition: • Collaborate with health care provider and dietitian to meet patient's nutritional and hydration needs. • Evaluate laboratory test results that may indicate malnutrition or dehydration. • If paralytic ileus is present, provide IV fluids and parenteral nutrition as prescribed, and monitor for return of bowel sounds. • Provide gastrostomy tube feedings if patient cannot swallow. • Assess the return of the gag reflex and bowel sounds before resuming oral nutrition.

Bell's Palsy

Nursing Interventions: -Administer corticosteroids -Administer analgesics -Administer heat to affected side of face • If the eye does not close completely or the blink reflex is diminished, protect it from injury with a protective shield at night. Teach the patient to close the eye manually before going to sleep or applying eye shield. • Wrap-around sunglasses or goggles may be worn during the day to decrease normal evaporation from the eye.

Nursing Interventions: -Exercise Program (improve coordination, dexterity, prevent contractures) -Teach Balance (concentrate on walking erect, looking at horizon, wide-based gait) -Adaptive and Assistive Devices, Consult w/ OT -Bowel Routine (fluids, fiber, raised toilet) -Stabilized plate, no-spill cup, utensils w/ boil-up handles -Assess for aspiration and pneumonia -possible tube feedings -Enhance swallowing (keep patient upright, semi-solid diet w/ thick liquids) -Coping mechanisms

myasthenia crisis

Nursing Interventions: -Maintain airway -Respiratory Assessment -Monitor Labs -NG feedings (dysphagia) -Intake and Output -Daily Weights NO SEDATIVES!!! (may exacerbate hypoxia and hypercapnia)

GBS

Nursing Interventions: -PRIORITY: MONITOR FOR RESPIRATORY FAILURE, and maintain respiratory function -Monitor for cardiac arrhythmias, autonomic dysfunction, DVT, and skin integrity -Enhance physical mobility -Provide nutrition • Assess swallowing, for paralytic ileus and nutritional status. • Assess/Decrease for fear and anxiety, as well as isolation, loneliness, and lack of control. -improve communication

Nursing Interventions: Patient Teaching: • Factors that exacerbate symptoms and potentially cause crisis should be noted and avoided: Emotional stress, infections (particularly respiratory infections), vigorous physical activity, some medications, and high environmental temperature. • Teach the patient strategies to conserve energy; help determine optimal times for rest throughout the day. If living in a two-storyhome, suggest that frequently used items such as hygiene products, cleaning products, and snacks be kept on each floor to minimize travel between floors.

ALS

Nursing Interventions: Same as MG PREVENT ASPIRATION, neuro checks, teaching coping

Nursing Interventions: • Supplemental feedings may be necessary in some patients to ensure adequate nutrition. • Instruct the patient to tape the eyes closed for short intervals and to regularly instill artificial tears to prevent corneal damage. Patients who wear eyeglasses can have "crutches" attached to help lift the eyelids; patching of one eye can help with double vision. • Remind the patient of the importance of maintaining health promotion practices and of following health care screening recommendations

Brain Tumor

Nursing Priorities: -Neuro Checks -Vital Signs -Maintaining Neuro Flow chart -preventing Increased ICP -reorienting patient -helping w/ self-care -preventing injury

Cranial Nerve I

Olfactory (smell)

3 and 8

On Glascow Coma Scale, a score between and is generally accepted as indicating a severe head injury.

Other Clinical Manifestations: • Autonomic symptoms include excessive and uncontrolled sweating, paroxysmal flushing, orthostatic hypotension, gastric and urinary retention, constipation, and sexual dysfunction • Cognitive and psychiatric changes are interrelated and include judgment, reasoning, decision making, and memory deficits, although intellect is not usually affected. • Personality changes, psychosis, depression, dementia, and acute confusion may occur, especially in the elderly. • Sleep disturbances may occur. • Auditory and visual hallucinations • Hypokinesia (abnormally diminished movement) is common. • Freezing phenomenon refers to a transient inability to perform active movement and is thought to be an extreme form of bradykinesia. • As dexterity declines, micrographia (small handwriting) develops. • Mask-like and expressionless facial expression develops, with decreasing frequency of blinking. • Dysphonia, soft, low-pitched, and less audible speech, develops. • Dysphagia, drooling, and risk for choking and aspiration develop.

GBS

Physical Assessment Findings: -Diaphragm muscle weakness (RESPIRATORY FAILURE) -Inability to Swallow, clear secretions -Tachycardia, bradycardia, hypertension, orthostatic hypotension (CARDIAC INSTABILITY ****Priority AIRWAY BREATHING CIRCULATION

Priority....Patient is at risk for falls!!

Plasmapheresis (plasma exchange)

Removal of patients plasma and plasma components Produces a temporary reduction in the antibodies Does not treat the underlying abnormality

Risk Factors: -3x more common in WOMEN before age 40 -2nd and 3rd decades in women -7th and 8th decades in men

hemorrhagic stroke

Severe headache, vomiting, early change in level of consciousness, and seizures are early signs of a ....stroke

What test is used to diagnose MG?

Tensilon Test

intellectual functioning

The client with damage to the fronal cortex will display a deficit

Decreased level of consciousness

The initial sign of increasing intracranial pressure (ICP) includes

ischemic stroke

The main presenting symptoms for .....stroke are numbness or weakness of the face, arm, or leg, especially on one side of the body, confusion or change in mental status, and trouble speaking or understanding speech

9, 10, 12

The nurse asks about difficulty speaking or swallowing to assess the functions of cranial nerves

diplopia and pstosis

The nurse is assessing a client newly diagnosed with myasthenia gravis. Which of the following signs would the nurse most likely observe?

rapid, jerky, involuntary movements

The nurse is caring for a patient with Huntington's disease in the long-term care facility. What does the nurse recognize as the most prominent symptom of the disease that the patient exhibits?

A, B, D. Nuchal rigidity, headache, Kernig's and Brudzinski's signs, and photophobia are classic signs of meningeal irritation. Aphasia, or difficulty speaking, and motor weakness are not typical signs of inflammation of the meninges.

The nurse knows that the signs and symptoms of meningeal irritation include which of the following? Select all that apply. A. Nuchal rigidity and headache B. Kernig's and Brudzinski's signs C. Aphasia and motor weakness D. Photophobia

The nurse knows that the signs and symptoms of meningeal irritation include which of the following? Select all that apply. Nuchal rigidity and headache Kernig's and Brudzinski's signs Aphasia and motor weakness Photophobia

cerebellar function

To evaluate ....., the nurse should ask the client about problems with balance and coordination.

Cranial Nerve V

Trigeminal

basilar skull

Type of fractures that are suspected when cerebrospinal fluid escapes from the ears or nose.

epidural hematoma

Usually a momentary loss of consciousness occurs at the time of injury, followed by an interval of apparent recovery (lucid interval)

atropine

What is the antidote/treatment for cholinergic (overmedication) crisis?

• Acetylcholinesterase medications with pyridostigmine bromide (Mestinon) -

What is the first line of medication therapy for MG? IT (increases concentration of acetylcholine at the neuromuscular junction)

Brain Tumor

What is the gold standard of diagnosing a brain tumor?

D. The demyelinating process of MS usually begins in the area of cranial nerve two, the optic nerve causing an optic neuritis, resulting in blurred vision in the affected eye. Diarrhea is not an initial symptom, later on in the course of the disease patients experience constipation. Very few MS patients experience a headache. Skin infections are rare with MS.

What is the most common initial symptom that a nurse might expect a client with MS to complain about? A. Diarrhea B. Headaches C. Skin infections D. Visual disturbances

What is the most common initial symptom that a nurse might expect a client with MS to complain about? Diarrhea Headaches Skin infections Visual disturbances

morning

When is the best time for a patient w/ MG to do activities?

Lehermitte's Sign

When you ask the patient to move the head and neck downward the patient reports an "electric shock" sensation that travels down the body. You would report your finding to the doctor that the patient is experiencing:

subarachnoid space

Where does CSF circulate?

baclofen and diazepam

Which medications below can help treat muscle spasms in a patient with multiple sclerosis?

D. hypertension. Early signs of rising ICP include headaches, seizures, nausea and vomiting, cognitive impairment, and visual disturbances such as papilledema. Late vital signs changes associated with rising ICP, termed Cushing's triad, include hypertension with a widening pulse pressure (the difference between systolic and diastolic pressure), bradycardia, and respiratory depression.

Which of the following are late signs of rising ICP? Papilledema Change in the LOC Vomiting Hypertension

menigiomas

Which of the following is a brain tumor arising from the supporting structures?

D. Tonic-clonic seizure is a type of generalized seizure in which the patient loses consciousness. Body stiffening describes the tonic phase of the seizure, and muscle contractions describe the clonic phase. Jerking in one extremity is a sign of a partial seizure that spreads into a generalized seizure. Vacant staring and abrupt cessation of activity is descriptive for an absence seizure. Facial grimaces, patting motions, and lip smacking are indicative of a partial seizure.

Which of the following will the nurse observe in the patient undergoing a tonic-clonic seizure? A. Jerking in one extremity that spreads gradually to adjacent areas B. Vacant staring and abrupt cessation of all activity C. Facial grimaces, patting motions, and lip smacking D. Loss of consciousness, body stiffening, and violent muscle contractions

Which of the following will the nurse observe in the patient undergoing a tonic-clonic seizure? Jerking in one extremity that spreads gradually to adjacent areas Vacant staring and abrupt cessation of all activity Facial grimaces, patting motions, and lip smacking Loss of consciousness, body stiffening, and violent muscle contractions

D. Due to the decrease in dopamine in the substantia nigra, the Parkinson's disease patient has a hard time initiating a spontaneous movement. With Parkinson's disease there is cogwheel rigidity, not flaccidity. Parkinson's disease is a resting tremor, not intentional. There is no paralysis with Parkinson's disease.

While assessing a client with Parkinson's disease, the nurse identifies bradykinesia when the client exhibits which of the following? A. Muscle flaccidity B. An intention tremor C. Paralysis of the limbs D. Slow spontaneous movement

While assessing a client with Parkinson's disease, the nurse identifies bradykinesia when the client exhibits which of the following? Muscle flaccidity An intention tremor Paralysis of the limbs Slow spontaneous movement

oligoclonal bands

Your patient is scheduled for a lumbar puncture to help diagnose multiple sclerosis. The patient wants clarification about what will be found in the cerebrospinal fluid during the lumbar puncture to confirm the diagnosis of MS. You explain that ____________ will be present in the fluid if MS is present.

ventriculostomy

a catheter placed in one of the lateral ventricles of the brain to measure intracranial pressure and allow for drainage of cerebrospinal fluid (CSF) or blood

Cushing's response

a compensatory response that attempts to restore blood flow by increasing arterial pressure to overcome the increased intracranial pressure; this includes rising systolic pressure, widening pulse pressure, and bradycardia

complete spinal cord lesion

a condition that involves total loss of sensation and voluntary muscle control below the lesion in the spinal cord

incomplete spinal cord lesion

a condition where there is preservation of the sensory or motor fibers, or both, below the lesion in the spinal cord

neurodegenerative

a disease, process, or condition that leads to deterioration of normal cells or function of the nervous system

epilepsy

a group of syndromes characterized by paroxysmal transient disturbances of brain function

primary headache

a headache for which no specific organic cause can be found

babinski reflex

a reflex action of the toes, indicative of abnormalities in the motor control pathways leading from the cerebral cortex

migraine headache

a severe, unrelenting headache often accompanied by symptoms such as nausea, vomiting, and visual disturbances

concussion

a temporary neurologic dysfunction caused by trauma to the head, classified as mild or classic based on symptoms (mild, without loss of consciousness or memory; classic, includes loss of consciousness and memory)

autoregulation

ability of cerebral blood vessels to dilate or constrict to maintain stable cerebral blood flow despite changes in systemic arterial blood pressure

clonus

abnormal movement marked by alternating contraction and relaxation of a muscle occurring in rapid succession

herniation

abnormal protrusion of tissue through a defect or natural opening

paresthesia

abnormal touch sensation (e.g., burning, tingling, numbness)

dysphonia

abnormal voice quality caused by weakness and incoordination of muscles responsible for speech

Autonomic Dysreflexia

also called autonomic hyperreflexia; a life-threatening emergency in spinal cord injury patients that causes a hypertensive emergency, occurs in patients with an injury at or above T6

vertigo

an illusion of movement in which the individual or the surroundings are sensed as moving, usually rotation

head injury

an injury to the scalp, skull, and/or brain

brain injury

an injury to the skull or brain that is severe enough to interfere with normal functioning

spinal cord injury (SCI)

an injury to the spinal cord, vertebral column, supporting soft tissue, or intervertebral disks caused by trauma

parietal lobe

analyzes sensor information and relays the interpretation to the cortical area. Failure to identify a familiar object by touch is indicative of .......lobe dysfunction

spondylosis

ankylosis or stiffening of the cervical or lumbar vertebrae

myasthenia gravis

antibodies directed at the acetylcholine receptor sites impair transmission of impulses across the myoneural junction

gliomas

are the most common brain neoplasms, accounting for about 45% of all brain tumors.

Romberg Test

assesses balance, which has to do with the cerebellar and basal ganglia influence on the motor system

position (postural) sense

awareness of position of parts of the body without looking at them; also referred to as proprioception

cerebral metastases

breast and lung cance

cerebral contusion

bruising of the brain surface

lower motor neuron lesions

cause flaccidity, muscle atrophy, decreased muscle tone, and loss of voluntary control.

upper motor neuron lesions

cause increased muscle tone, hyperactive and abnormal reflexes

locked-in syndrome

condition due to a lesion at or below the pons or midbrain, which results in the inability to movement while consciousness is preserved; communication is severely limited

altered level of consciousness

condition of being less responsive to and aware of environmental stimuli

CN VI Abducens

cranial nerve supports movement of the eye laterally. Damage to the nerve can cause double vision.

dysphagia

difficulty swallowing, causing the patient to be at risk for aspiration

radiculopathy

disease of a nerve root

parasympathetic nervous system

division of the autonomic nervous system active primarily during nonstressful conditions, controlling mostly visceral functions

sympathetic nervous system

division of the autonomic nervous system with predominantly excitatory responses; the "fight-or-flight" system

autonomic nervous system

division of the nervous system that regulates the involuntary body functions

diplopia

double vision, or the awareness of two images of the same object occurring in one or both eyes

laminectomy

excision of the posterior arches and spinous processes of a vertebra

secondary headache

headache identified as a symptom of another organic disorder (e.g., brain tumor, hypertension)

bulbar paralysis

immobility of muscles innervated by cranial nerves with their cell bodies in the lower portion of the brainstem

dyskinesia

impaired ability to execute voluntary movements

ataxia

inability to coordinate muscle movements, resulting in difficulty in walking, talking, and performing self-care activities; irregular, uncoordinated movements

rigidity

increase in muscle tone at rest characterized by increased resistance to passive stretch

brain death

irreversible loss of all brain function, including the brainstem

subdural hematoma

is a collection of blood between the dura and the brain, a space normally occupied by a thin cushion of cerebrospinal fluid. After a head injury, blood may collect in the epidural (extradural) space between the skull and the dura.

trigeminal neuralgia

is a condition of the fifth cranial nerve that is characterized by paroxysms of sudden pain in the area innervated by any of the three branches of the nerve. Paroxysms can occur with any stimulation of the terminals of the affected nerve branches, such as washing the face, shaving, brushing the teeth, eating, and drinking.

plasmapheresis

is a technique in which antibodies are removed from plasma and the plasma is returned to the client

chorea

is an abnormal involuntary movement derived from the Greek word "dance". It is characterized by brief, abrupt, irregular, unpredictable, non-stereotyped movements.

Autonomic Dysreflexia

is an acute emergency and is seen in clients with a cervical or high thoracic spinal cord injury, usually after the spinal shock subsides

intracerebral hematoma

is bleeding within the brain, into the parenchyma of the brain. It is commonly seen in head injuries when force is exerted to the head over a small area (e.g., missile injuries, bullet wounds, stab injuries).

parietal lobe

is essential to a person's awareness of body position in space, size and shape discrimination, and right-left orientation

agnosia

loss of ability to recognize objects through a particular sensory system; may be visual, auditory, or tactile

spasticity

muscular hypertonicity with increased resistance to stretch often associated with weakness, increased deep tendon reflexes, and diminished superficial reflexes

paraplegia

occurs with injuries at the thoracic level.

photophobia

ocular pain on exposure to light

Cranial Nerve III

oculomotor nerve

Cranial Nerve II

optic nerve

focal

or localized, symptoms include muscle weakness, sensory loss, aphasia, and visual changes.

Tetraplegia (quadriplegia)

paralysis of both arms and legs, with dysfunction of bowel and bladder from a lesion of the cervical segments of the spinal cord

paraplegia

paralysis of the lower extremities with dysfunction of the bowel and bladder from a lesion in the thoracic, lumbar, or sacral regions of the spinal cord

seizures

paroxysmal transient disturbance of the brain resulting from a discharge of abnormal electrical activity

dendrite

portion of the neuron that conducts impulses toward the cell body

decerebrate

posturing is the result of lesions at the midbrain and is more ominous than decorticate posturing. The described posturing results from cerebral trauma and is not normal. The patient has no motor function, is limp, and lacks motor tone with flaccid posturing.

decorticate

posturing is when a client is stiff with bent arms and clenched fists with legs straight out.

intracranial pressure

pressure exerted by the volume of the intracranial contents within the cranial vault

coma

prolonged state of unconsciousness

tetraplegia

results in the paralysis of all extremities when there is a high cervical spine injury

transection

severing of the spinal cord itself; transection can be complete (all the way through the cord) or incomplete (partially through)

microphagia

small and often illegible handwriting

Romberg test

test for cerebellar dysfunction requiring the patient to stand with feet together, eyes closed, and arms extended; inability to maintain the position, with either significant stagger or sway, is a positive test

medulla oblongata

the part of the brainstem that contains vital centers concerned with respiration, heartbeat, and vasomotor activity (the control of smooth muscle activity in blood vessel walls).

Monro-Kellie hypothesis

theory that states that due to limited space for expansion within the skull, an increase in volume of any one of the cranial contents—brain tissue, blood, or CSF—must be compensated for by a decrease in volume of another

Cushing's Triad

three classic signs—bradycardia, hypertension, and bradypnea—that represent a loss of compensatory mechanisms a presentation of brainstem dysfunction

delirium

transient loss of intellectual function, usually due to systemic problems

Cranial Nerve IV

trochlear nerve

Tensilon test

• An acetylcholinesterase test using an injection of edrophonium (Tensilon) is used to confirm the diagnosis. Immediate improvement in muscle strength represents a positive test and usually confirms the diagnosis. -Used to diagnose MG and to differentiate between myasthenic crisis and cholinergic crisis.

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