Neuro Part 2 Chapter 67, 69-70
Dysarthria
Defects of articulation d/t neurologic causes
Ischemic stroke manifestations
Depend on location & size of affected area Numbness or weakness or the face, arm, or leg, especially on one side Confusion or change in mental status Trouble speaking/understanding speech Difficulty walking, dizziness, loss of balance or coordination Severe, sudden HA Perceptual disturbances
What are the psychiatric changes seen in Parkinson's Disease?
Depression Anxiety Dementia Delirium Hallucination
Dysphagia
Difficulty swallowing
which finding would the nurse expect to observe in an initial assessment of a client with myasthenia gravis?
ptosis and diplopia (droopy eyelid, double vision)
Receptive aphasia
Inability to understand what someone else is saying
Fungal Meningitis CSF
Opening Pressure: >200 WBC count >20 Glucose: <40
Extramedullary/extradural
Outside dural membrane
Deep brain stimulation
Pacemaker for brain patient with Levodopa success & dyskinesias impaired had disease for at least 5 years disabled by tremor May increase dopamine release May block anticholinergic release * Improves tremor and rigidity
Hemiplegia
Paralysis of one side of the body, or part of it, due to an injury in the motor area of the brain
Vector-born manifestations
rash flaccid paralysis Parkinson-like movement
Types of meningitis
septic aseptic
the nurse is aware that, when assessing a patient for symptoms of a brain tumor, the symptom most frequently found is:
simple to generalized seizures
a nurse is assessing a client with Parkinson's disease. Which of the following would the nurse expect to find?
slowing of activity
Brain tumor medical management
specific treatment depends on * type/location/accessibility Surgery Chemotherapy Medications
Parkinson's Disease surgical procedures
stereotatic Thalamotomy/pallidotomy * Destroy brain tissue, rarely used today Deep brain stimulation
What should happen if a patient on tPA starts bleeding
stop tPA get CT scan give antidote * Tranexamic Acid (TXA)
What should happen if a patient on tPA ℅ HA
stop tPA, contact MD for CT
which of the following provides the best outcome for most tumor types?
surgery
a client has been diagnosed with trigeminal neuralgia. The nurse should recognize what implication of this diagnosis?
the client needs to be assessed for MS
when should the nurse plan the rehabilitation of a patient who is having an ischemic stroke?
the day the patient has the stroke (only delay if they are on TPA)
Trigeminal neuralgia
tic douloureaux
Hemianopsia
Blindness of half of the field of vision in one or both eyes
Types of MS
Relapse-remitting Primary progressive **WORST Secondary progressive Progressive-relapsing
What are the cardinal manifestations of parkinsons disease?
tremor rigidity bradykinesia, akinesia postural instability dysphagia
How do tumors look on a CT
tumors are more solid
How does an abscess look on a CT
typically have a more/better defined edge
Vasospasm risk
up to 21 days after SAH
what should the nurse tell the client to explain the long length of stay after a SAH?
vasospasms are a risk up to 21 days after SAH
Encephalitis causes
viral infections (herpes simplex) * Most common vector-born viral infections (west nile, St. Louis) Fungal infections * not often seen in healthy patients
which of the following would the nurse identify as the primary initial symptoms of an ischemic stroke?
weakness on one side of the body and difficulty with speech
brudzinski sign
when patient lying flat, neck is bent forward (chin toward chest), this causes the hips to flex
Kernig sign
when patient lying with thigh flexed on the abdomen, the leg cannot be completely extended
Malignant
Invades/spreads
AMYOTROPHIC LATERAL SCLEROSIS (ALS)
"Lou Gehrig's" Loss of motor neurons in anterior horn Loss of motor nuclei in lower brain stem
a nurse is teaching a client who was recently diagnosed with myasthenia gravis. Which statement should the nurse include?
"this disease doesn't cause sensory impairment" (motor impairment)
tPA
18 or older Clinical dx ischemic stroke <3 hrs since onset of symptoms (can wait up to 4.5 hrs) Systolic BP 185 or less, diastolic BP 110 or less No seizure at onset of stroke No heparin in the past 48 hrs Plt ct 100000 or more Glucose > 50 no prior intracranial hemorrhage, neoplasm, AVM or aneurysm No major surgical procedures or serious trauma w/in 14 days No stroke, serious head injury or intracranial surgery w/in 3 months No GI/GU bleeding w/in 21 days No pregnancy
CJD & vCJD Manifestations
Affective, sensory, motor and cognitive impairments Takes years for clinical signs to show up Once signs have appeared lifespan is about 22 months for vCJD and 1 year for CJD
Secondary prevention
After CVA/TIA Trying to keep pt from having another stroke Carotid endarterectomy for carotid stenosis Anticoagulant Tx for A-Fib (Coumadin-Warfarin) Antiplatelet therapy Statins Antihypertensive medications
Nonmodifiable risk factors of stroke
Age (older than 55) Gender (Males > Females) Race (more in African Americans)
Degenerative disc disease changes occur with
Aging * Twisting & moving wears disc down over time Result of trauma
which of the following, if left untreated, can lead to an ischemic stroke?
A-fib
Arterial venous malformations
AVM artery and vein are connected Causes increased arterial pressure
Encephalitis
Acute, inflammatory process of the brain tissue
Spinal cord tumors classified according to
Anatomic relation to spinal cord
Ischemic Stroke
Approximately 87% of all strokes Disruption of the blood supply caused by an obstruction, thrombus or embolism, causes infarction of brain tissue
Penumbra region
Area of low cerebral blood flow associated with a stroke Tissue may be salvaged with quick intervention
Primary tumor
Arise from brain tissue
if warfarin is contraindicated as a treatment for stroke, which medication is the best option?
Aspirin
Trigeminal neuralgia management
Antiseizure meds Carbamazepine (Tegretol) Gabapentin (Neurontin) Phenytoin Antispasmodic Baciofen (Lioresal) Surgery Microvascular decompression of CN V Radiofrequency thermal coagulation
Hemorrhagic Stroke
Approximately 13% of all strokes Caused by bleeding into brain tissue, the ventricles, or subarachnoid space Brain metabolism disrupted by exposure to blood ICP increases d/t blood in subarachnoid space Compression and secondary ischemia results from reduced perfusion and vasoconstriction
Stroke post-acute phase medical management
Assess mental status Sensation/perception swallowing ability nutritional & hydration status skin integrity activity tolerance bowel & bladder function
Myasthenia Gravis
Autoimmune disorder affecting the myoneural junction and is characterized by varying degrees of voluntary muscle weakness Antibodies attack receptor site * Little or no acetylcholine available * Muscles can't contract Motor disorder * Autoimmune affecting myoneural junction
Guillain-Barre syndrome
Autoimmune disorder with acute attack of peripheral nerve myelin Very fast! Peak within 2-4 weeks Rapid demyelination may produce respiratory failure and ANS dysfunction w/ CV instability Most often follows viral infection
a client with Guillain
Barre states, "it's getting harder to take a deep breath" what should the nurse do?-call the physician and prepare for intubation
a client is hospitalized with Guillain
Barre. Which nursing assessment finding is most significant?-even, unlabored respirations (because you know they're not in danger yet, no interbentions needed)
Spinal cord tumor assessment
Baseline neurologic exam Patient function/moving/walking Adaptation to weakness/paralysis/vision & speech loss/seizures Pain Respiratory systems Bowel & bladder function Sleep Skin integrity Fluid balance Temperature regulation Nutritional history Family coping/processes
Trigeminal neuralgia (tic douloureux)
CN V Extremely painful 2nd & 3rd branches of nerve Vascular compression/pressures probable cause Mainly in women age 50-60 years/people with MS
Acoustic neuroma
CN VIII Slow growing so gets really big before symptoms noticeable Brain compensates Might notice hearing loss/vertigo Eventually brain can't compensate
Stroke diagnosis
CT Scan Cerebral angiography Lumbar puncture If CT is negative & ICP not elevated Confirms SAH
Cerebral Vascular Accident
CVA Stroke Brain Attack
Stroke management
Care primarily supportive Bed rest w/ sedation Oxygen Tx of vasospasm, increased ICP, HTN, potential seizures Prevention of further bleeding
Huntington's disease
Chronic progressive hereditary disease that results in Choreiform movement * Rapid, jerky movements/tics Dementia
Brain Abscess
Collection of infectious material within brain tissue Bacteria the most common causative organism Prevented by treating otitis media, rhinosinusitis CT-guided aspiration used to ID causative organisms
Brain abscess medical management
Control ICP Drain abscess Admin ABT therapy Corticosteroids possibly for cerebral edema
Parkinson's Disease treatment
Directed at controlling symptoms Maintaining functional independence:Parkinson's Disease pharmacological treatment-Lovadopa * Most effective/mainstay of treatment * Converted to dopamine in basal ganglia - gives relief of symptoms * Side effects become more severe over time - Dyskinesia - On-off syndrome (immobility followed by return to effectiveness) - Nausea/vomiting/appetite loss - Decreased BP - Dystonia/dyskinesia/confusion Cogentin * Counteract action of acetylcholine (anticholinergic)
Myasthenia Gravis Medical Management
Directed at improving function/reducing & removing circulating antibodies Antichoinesterase medications * Pyridostigmine bromide * Use 1st due to less side effects * Gets rid of cholinesterase * More acetylcholine is available due to open receptor sites IV immune globulin (IVIG) * Corticosteroids - Prednisone * Azathioprine (Imuran) * Immune suppressant/Cytotoxic/Last resort Plasmapheresis * Removes antibodies * Thymectomy
Medical Management of MS
Disease-modifying therapies IV methylprednisolone shortens the relapse *no long-term effect Symptom management of Muscle spasms Fatigue Ataxia Bowel & bladder control Glatiramer acetate reduces rate of relapse Most medications ineffective for progressive course!
Glioblastoma
Divide/grow faster Grades 3 & 4
Benign tumor
Doesn't invade/spread
Spinal cord tumor manifestations
Early manifestation * Pain Weakness Loss of motor function Loss of reflexes Loss of sensation Tumor at Cervical area * Respiratory changes
Vasospasm
Early signs of stroke. If treated quickly stroke can be prevented
Myasthenia crisis management
Educate patient in signs & symptoms of MG and CC Make sure patient isn't over-medicated to cause CC Ensure adequate ventilation * Intubation & mechanical ventilation may be needed Assessment & supportive measures * Ensure airway & respiratory support * ABGs, serum electrolytes, I & O, daily weight * NG tube if patient can't swallow * NO SEDATIVES/TRANQUILIZERS - Don't knock out what little function exists
Trigeminal neuralgia interventions
Education * Pain prevention * Treatment regimen * Side effects of seizure medicine * Avoid triggers Strategies to improve nutrition * Soft food * Chew on unaffected side * Avoid hot/cold food Provide interventions to address * Anxiety * Depression * Insomnia
the nurse is caring for a client with aphasia. Which strategy will the nurse use to facilitate communication?
Establishing eye contact
Stroke acute phase medical management
Evaluate by CT (looking for blood) Lumbar puncture if SAH believed to be happening Elevate HOB - unless contraindicated Neuro assessment & vital signs LOC Monitor for pupil changes I & O O2 saturation
S/S seen with exacerbation of MS
Fatigue Weakness Numbness Coordination difficulty Loss of balance Pain Visual disturbances
Meningitis nursing management
Freq or continual assessment, including VS & LOC Pain & fever management Protect from injury r/t seizure activity or LOC Monitor daily wt, serum electrolytes, urine volume, specific gravity, osmolality Prevent immobility associated complications Supportive care
Stereotatic procedures
GAMMA knife * very targeted, really high radiation Non-invasive A week or more before results seen laser could cause necrosis
Meningitis manifestations
HA fever LOC changes behavioral changes nuchal rigidity (stiff neck) Positive kernig sign positive brudzinski sign photophobia
which finding would nurse expect on initial assessment of a client with possible brain abscess?
HA that is worse in the morning
Brain abscess manifestations
HA, usually worse in the morning Fever Vomiting Neuro deficits S/S increased ICP
Modifiable risk factors of stroke
HTN primary DM * Greater risk when combined with HTN Cardiovascular disease Elevated cholesterol Elevated hematocrit Obesity Oral Contraceptive use Smoking Drug & Alcohol abuse
Process of demyelination
Immune system destroys myelin sheath! Inflammation destroys myelin sheath Conduction interrupted
Multiple Sclerosis (MS)
Immune-mediated , progressive demyelinating disease of the CNS Clinical manifestations vary and have different patterns Frequent relapse & remission Can cause social isolation due to debilitating pain & fatigue! Patients degenerate
Guillain-Barre syndrome planning
Improved * Respiratory function, mobility, nutrition, communication, coping Decreased fear & anxiety Absence of complications As patient gets better these conditions will improve
Astrocytoma
In astrocytes of glial cells Slow growing Grades 1 & 2
Meningiomas
In meninges
Expressive aphasia
Inability to express oneself often associated with damage to the left frontal lobe area
Aphasia
Inability to express oneself or to understand language
Apraxia
Inability to perform previously learned purposeful motor acts on a voluntary basis
Creutzfeldt
Jakob Disease (CJD) & variant Creutzfeldt-Jakob Disease (vCJD)-AKA Mad-Cow disease Rare, degenerative infectious, transmissible spongiform encephalopathies (TSEs) Caused by prions (smaller than viruses & resistant to sterilization) Not spread via casual contact * Carried in CSF and eye fluid
which is a component of the nursing management of the client with variant Creutzfeldt
Jakob disease (CJD)?-providing palliative care (it's a 100% fatal disease)
Vasospasm Treatment
Keep fluid volumes up Calcium Channel blockers * Nimodipine Keep BP up
What to monitor with tPA
LOC ℅ HA CT or MRI 24 hrs after tPA starts.
Ischemic stroke causes
Large artery thrombosis Small penetrating artery thrombosis Cardiogenic embolic Cryptogenic, no known cause Other
Brain tumor manifestations
Localized or generalized symptoms Symptoms of increased ICP * Altered LOC due to brain compensating Headache Vomiting * Vagal center in medulla Vision disturbances Seizures * 60% will have seizure
Brain tumor classification based on
Location Histologic characteristics * Mitosis of cell
Agnosia
Loss of ability to recognize objects through a particular sensory system
Brain abscess diagnosis
MRI or CT
Bell Palsy Management
Medical * Corticosteroid therapy - Reduce inflammation/diminish severity Nursing * Provide education & reassurance that stroke hasn't happened * Protect eye from injury!! - Raised eye shield at night - Ointment/sunglasses * Facial exercises/massage - To maintain muscle tone
Guillain-Barre syndrome medical management
Medical emergency!! Requires ICU management w/ continuous monitoring & respiratory support - intubation Plasmapheresis & IVIG To reduce circulating antibodies Recovery rates vary, most completely recover Chronic disease Will always have so avoid triggers
Degenerative disc disease medical management
Medications * pain medicine * dexamethasone * injected corticosteroid * muscle relaxant Surgery may be required
Infectious Neurologic Disorders
Meningitis Brain abscess Encephalitis Crutzfeldt-Jakob disease or variant Crutzfeldt-Jakob disease
Duchenne muscular dystrophy
Most common Inherited as sex-linked trait Passed from fathers because x chromosome linked
Glioma
Most common in cerebral tissue Glial cells surround neurons and give support Can infiltrate any portion of brain Astrocytoma Glioblastoma Meningioma Acoustic neuroma Pituitary adenoma
Diagnostic tests for brain tumor
Neurologic exam * Check deficits CT * Check for tumor MRI * Differentiate between tumor & abscess PET * Detect cancer cells EEG * Seizure activity Cytologic study of cerebrospinal fluid Biopsy
a client has had a SAH (subarachnoid hemorrhage). the nurse anticipates which therapeutic intervention?
Nimodipine PO, CCB(reducing risk of vasospasms)
CJD & vCJD Treatment
No effective treatment, progressive and fatal
Myasthenia Gravis Manifestations
Ocular muscles initially Diplopia Ptosis Facial muscle weakness Impaired swallowing Impaired, nasally voice (dysphonia) Generalized weakness
Guillain-Barre syndrome Assessment
Ongoing assessment with emphasis on Respiratory failure Make sure they can breathe!! Cardiac dysrhythmias DVT Patient & family coping HUGE!
Normal CSF
Opening Pressure: 100-180 WBC count: 0-5 Glucose: 45-80 (0.6x blood glucose level)
Bacterial Meningitis CSF
Opening Pressure: 200-500 WBC count: 100-5000 Glucose <40 (0.4x blood glucose level)
Viral Meningitis CSF
Opening Pressure: 250 or greater WBC count: 50-1000 Glucose: >45
Huntington's disease pathophysiology
Premature death of cells Basal ganglia (movement control) Cortex (thinking/memory/perception/judgement) Cognitive impairment Behavioral problems Progressive/gets worse
Meningitis medical management
Prevention through the meningococcal vaccine * 11-12 years old * booster 16 years old * First year college students * Military members Early admin of high doses of IV antibiotics Must cross the blood brain barrier * PCN-G or cephalosporins * Dexamethasone Tx for shock, dehydration & seizures
ALS Manifestations
Progressive weakness, atrophy Cramps, twitching, lack of coordination Spasticity, DTR brisk and over-active Difficulty speaking, swallowing, breathing Doesn't affect cognition
Aneurysm Precautions
Provide non stimulating environment (prevent increase of ICP), dim lighting, no reading, no TV, no radio Absolute bed rest HOB 30 degrees No extreme flexion of the hips, increases intraabdominal pressure which increases ICP Stool softeners & mild laxatives No acute flexion of head or neck Restrict visitors Keep BP on the lower side
Cholinergic Crisis
Rare Caused by overmedication of cholinesterase inhibitors Severe muscle weakness w/ respiratory & bulbar weakness Patient may develop respiratory compromise failure
Brain tumor surgery
Remove tumor without increasing symptoms Relieve symptoms by decompression Best thing to do is to take out tumor!! Craniotomy Transsphenoidal Stereotatic procedures Radiation
Guillain-Barre syndrome collaborative problems/complications
Respiratory failure ANS dysfunction DVT/PE Urinary retention
Myasthenia crisis
Result of exacerbation or precipitating event Usually respiratory infection Severe generalized muscle weakness w/ respiratory & bulbar weakness Patient may develop respiratory compromise failure
Subarachnoid hemorrhage
SAH Bleeding in the subarachnoid space
Encephalitis manifestations
Seizures HA Fever Confusion Hallucinations
ALZHEIMER'S
Senile dementia Most common cause of dementia Chronic/progressive/degenerative brain disorder Oxidative stress plays roll
Continued pressure on disc may cause changes in
Sensation & motor responses
Hemorrhagic Stroke Manifestations
Severe HA Early & Sudden changes in LOC Vomiting - Projectile Bleeding
Hemorrhagic Stroke Causes
Spontaneous rupture of small vessels primarily related to HTN Subarachnoid hemorrhage caused by a ruptured aneurysm intracerebral hemorrhage r/t amyloid angiopathy Arterial venous malformations (AVMs) Intracranial aneurysms Anticoagulant medications
CJD
Sporadic * no reason to happen * we don't know why Heredity * genetic disorder Acquired * eat it or it gets into your body somehow physical symptoms seen first
What are the autonomic manifestations of Parkinson's Disease?
Sweating Drooling Flushing Orthostatic Hypotension Gastric & Urinary retention
Transient Ischemic Attack
TIA or Mini-stroke Temporary deficit resulting from temporary impairment of blood flow Stroke-like symptoms that resolve on their own "warning of impending stroke" Diagnostic workup required to treat and prevent irreversible deficits
Infarction
Tissue necrosis in an area deprived of blood supply
N. meningitidis
Transmitted by secretions or aerosol contamination infection is likely in dense community groups like college campuses
Hormonal effects with pituitary adenoma due to pituitary being over hypothalamus
Tumor secretes same hormone that pituitary does causing hormone overload * Mood swings * Eating * Blood pressure
Guillain-Barre syndrome interventions
Turn Q2H Assess swallowing/gag reflex to prevent aspiration Compression hose/SCDs Passive ROM at least 2x a day Limbs in functional position Need to have a plan to communicate with patient!!
Spinal cord tumor treatment depends on
Type & location of tumor Surgical removal is most desirable To relieve compression * Dexamethasone combined w/ radiation
Bell Palsy manifestations
Unilateral facial muscle weakness/paralysis * Facial distortion/one side of face drooped * Increased lacrimation * Painful facial sensation Difficulty with speech/eating
MS Intervention
Use collaborative approach * best and only way to treat patients Activity & rest Bowel & bladder control Reinforce/encourage swallowing instructions Strategies to reduce aspiration risk Enhance cognitive function Minimize stress Maintenance of environment temp Assistive devices Modifications for home care management/independence of ADLs Coping support
Guillain-Barre syndrome manifestations
Variable Weakness Paresthesias Pain Diminished/absent reflexes Begin in lower extremities and progress upward Bulbar weakness Cranial nerve symptoms Tachycardia Bradycardia HTN or hypotension
Duchenne muscular dystrophy characteristics
Varying degrees of muscle wasting/weakness Abnormal elevation in muscle enzyme serum levels
Pituitary adenoma
Vision changes due to pituitary being located over optic chiasma & optic nerve
Goals for patients with neuro disorders
Want patient to function at highest possible level Watch for side, effects & depression Monitor for falls/major falls risk!! Ensure realistic goals or patient may become depressed Attaining adequate nutrition Hard to eat due to tremors Dysphagia
Trigeminal neuralgia pain can occur with
Washing face brushing teeth eating draft of air Patients might avoid all these to prevent attack
Hemiparesis
Weakness of one side of the body, or part of it, due to an injury in the motor area of the brain
Intramedullary
Within the cord
which is the primary medical management of vector-born encephalitis?
controlling seizures and increased ICP
Radiation
cornerstone treatment for many brain tumors used often to shrink/de-bulk to relieve ICP symptoms
Encephalitis medical management
acyclovir for HSV infection Amphotericin or other antifungal for fungal infection
Huntington's disease is transmitted as
autosomal dominant trait
Primary prevention
best way before CVA occurs
Intraparenchymal (intracerebral) bleed
bleeding in the brain tissue
Intraventricular bleed
bleeding in the vascular system
the client has had an ischemic stroke. what action should the nurse perform to best prevent joint deformities?
place a pillow in the axilla when there is limited external rotation
Septic
caused by bacteria (streptococcus pneumoniae, neisseria meningitidis)
Aseptic
caused by viral infection secondary to cancer or weak immune system
a client reports a HA in the occipital area and shows ataxia and nystagmus. Which is the most likely cause?
cerebellar abscess
which sign of meningitis is exhibited when the client's neck is flexed and flexion of the knees and hips is produced?
positive Brudzinski sign
Brain tumor pharmacologic therapy
dexamethasone for swelling/HA Mannitol Keppra for seizures
Parkinson's disease is associated with decreased levels of:
dopamine
What neurotransmitter is decreased with Parkinson's Disease?
dopamine
a client is diagnosed with a stroke is having difficulty forming words (motor function, marbled talk) during communication, this is:
dysarthria (marbled talk)
what is the nurse's most appropriate action for a client not receiving treatment for brain metastases?
ensuring that the client receives adequate palliative care or helping them be independent
a nurse is providing care to a client who has had a stroke. which symptoms are consistent with right-sided hemiplegia (Paralysis)?
expressive aphasia, (left hemisphere controls right side of body & includes the language centers)
Bell Palsy
facial paralysis caused by unilateral inflammation of CN VII most patients recover in 3-5 weeks Usually only have it once
which action should the nurse take first to promote client comfort after a lumbar laminectomy?
help the client assume a more comfortable position
the nurse is caring for a client with an inoperable brain tumor. What is the major threat to this client?
increased ICP
Muscular dystrophies
incurable disorders characterized by progressive weakening, wasting of skeletal & voluntary muscles Most are inherited
Meningitis
inflammation of the pia mater, the arachnoid and the CSF filled subarachnoid space Can be caused by bacteria, fungus, or virus N. meningitidis most common
the nurse recognizes the client is demonstrating late signs of ICP when which sign is observed?
irregular respirations (cushings triad, impending herniation)
What do neurologist prefer to give warfarin to prevent CVA?
it is easily reversed with Vitamin K
Brain tumor symptoms depend on
location/size of lesion
What can cause death in Alzheimer's patients?
malnourishment Aspiration PNA
vCJD
may be contracted through ingestion of infected beef Psychological symptoms seen first
a client is diagnosed with ALS the nurse understands that the symptoms of the disease will begin in what way?
numbness and tingling in the lower extremities
S/S CSF leak post
op-Serosanguinous drainage Bulging at site Continuous growing bulge called pseudo-meningiocele * Possible opening in the dura
what change in health status would then nurse attribute to the client's newly diagnosed metastatic brain disease?
personality changes
Transsphenoidal
pituitary tumor watch for CSF leak Diabetes insipidus d/t damaged pituitary that makes too much ADH
