Adult Health II Exam #3

Cushing's Triad

Changes in vital signs that occur in patients with increased ICP. This includes an increased systolic BP (Widening pulse pressure), decreased pulse, and irregular respiratory pattern. If this is occurring, it indicates that herniation may occur soon and this is an emergency situation.

BEFAST; facial drooping; slurred speech.

Clinical manifestations for stroke can be observed for using the acronym ____________, which includes balance off, eyes (unclear vision-usually unilateral), ________ _________, Arm or leg weakness on one side, __________ ________, and time lost (time is very important because it determines how we will treat the stroke).

intracranial regulation

Compliance and maintenance of having a balance that creates an environment that promotes normal brain functioning.

Perfusion

Consistent supply of blood, which delivers nutrients and O2 to the brain. It can be impacted by vessel blockage, severely low BP, and loss of vessel integrity due to pressure. Examples of this include ischemic stroke and intracranial hemorrhage. This affects intracranial regulation.

C. Checking that the cervical collar was correctly placed by EMS

Spinal precautions are ordered for the client, who sustained a neck injury during an MVA. The client has yet to be cleared that there is no cervical fracture. Which action is the nurse's priority when receiving the client in the ED? A. Assessing the client using the Glasgow Coma Scale (GCS) B. Assessing the level of sensation in the client's extremities C. Checking that the cervical collar was correctly placed by EMS D. Applying antiembolism hose to client's lower legs

D. Side-lying with head elevated 30 degrees

The nurse is caring for a patient after a head injury. How should the nurse position the patient in bed? A. Prone with the head turned to the right side B. High-Fowler's position with the legs elevated C. Supine position with the head on two pillows D. Side-lying with head elevated 30 degrees

C. Poor impulse control

The nurse is caring for the client who had a stroke affecting the right hemisphere of the brain. The nurse should assess for which problem initially? A. Right hemiparesis B. Expressive aphasia C. Poor impulse control D. Tetraplegia

B. Urinary output 1500 mL over 4 hours

The nurse is caring for the client who has severe craniocerebral trauma. Which finding indicates that the client is developing DI? A. Blood glucose level at 230 mg/dL B. Urinary output 1500 mL over 4 hours C. Urine specific gravity at 1.042 D. Somnolent when previously alert

B. A positive Brudzinski's sign

The nurse is evaluating the status of a client who had a craniotomy 3 days ago. The nurse would suspect the client is developing meningitis as a complication of surgery if the client exhibits: A. A negative Kernig's sign B. A positive Brudzinski's sign C. A Glasgow coma scale score of 15 D. Absence of nuchal rigidity

A. Displacement of brain tissue

The nurse is implementing interventions for the client who has increased ICP. The nurse knows that which result will occur if the increased ICP is left untreated? A. Displacement of brain tissue B. Increased Cerebral perfusion C. Increased serum pH level D. Leakage of CSF

Tetrabenazine

The only drug that helps with chorea. It decreased dopamine and helps treat Huntington's disease.

C. Notify the provider if signs of increased intracranial pressure are present

A patient is admitted with a headache, fever, and general malaise. The HCP has asked that the patient be prepared for a lumbar puncture. What is a priority nursing action to avoid complications? A. Evaluate laboratory results for changes in the white cell count B. Give acetaminophen for the headache and fever before the procedure C. Notify the provider if signs of increased intracranial pressure are present D. Administer antibiotics before the procedure to treat the potential meningitis

D. Decreasing level of consciousness

A patient with increased ICP is positioned in a lateral position with the head of bed elevated 60 degrees. The nurse evaluates a need for lowering the head of the bed when the patient experiences: A. Ptosis of the eyelid B. Nausea C. A decrease in motor functions D. Decreasing level of consciousness

D. A normal balance among brain tissue, blood, and cerebrospinal fluid.

A patient with intracranial pressure monitoring has a pressure of 12 mmHg. The nurse understands that this pressure reflects? A. A severe decrease in cerebral perfusion pressure B. An alteration in the production of cerebrospinal fluid C. The loss of autoregulatory control of intracaranial pressure D. A normal balance among brain tissue, blood, and cerebrospinal fluid.

Viral meningitis

A self-limiting illness meningitis that is transmitted from person to person. It is usually caused by enterovirus (enteric GI and respiratory secretions), insects (west nile), and body fluids (herpes and flu). Getting vaccinations (flu, pneumonia, MMR, and chicken pox) and avoiding mosquito bites and crowded areas help to prevent this type of meningitis. Treatment is primarily symptom management. Encourage fluid intake and there is limited use of antivirals only if herpes or influenza virus in origin.

Tensilon test

A test that is used to diagnose Myasthenia gravis in which an edrophonium chloride injection is given IV to a patient. This med blocks Ach break down and increases Ach in the body, so symptoms will improve. This test is also used to differentiate between MG and a cholinergic crisis.

1. Changes in LOC- they may have decreased orientation and attention and flat affect and can eventually go into a coma. 2. Eyes- Papilledema, pupillary changes (dilated or pinpoint), and impaired eye movement. 3. Posturing-Decorticate (flexor) or Decerebrate (extensor)

What should you assess first if you suspect a patient may have increased ICP?

1. Transluminal angioplasty- insert balloon to open artery. 2. Stenting 3. Carotid endarterectomy- Remove clot in carotid artery

What surgical interventions can be used for TIA management?

-CO2- potent vasodilator -O2- Potent vasoconstrictor -Hydrogen ion concetration- very acidic, can cause more vasodilation. Occurs when O2 levels are low and lactic acid increases. CO2 and O2 levels need to be balanced.

What three factors affect cerebral blood vessel tone?

B. A 65-yr-old black man with HTN

Which patient has the highest risk for having a stroke? A. An obese 45-yr-old Native American B. A 65-yr-old black man with HTN C. A 35-yr-old Asian American worman who smokes D. A 32-yr-old white woman taking oral contraceptives

Antiviral agents- Amontadine

A drug that stimulates dopaminergic receptors by causing an increase in dopamine release and blocking reuptake. This helps provide mild relief of symptoms and is usually used in earlier stages of Parkinson's disease.

Linear/depressed skull fracture

A head injury that occurs when the skull is fractured in a straight line in continuity of bone with no bone fragments. It is usually associated with a powerful blow.

risk for aspiration

A nurse is performing a neurologic assessment on a client with a stroke and cannot elicit a gag reflex. This deficit is related to cranial nerve X, the vagus nerve. What will the nurse consider a priority nursing diagnosis?

C. Increased appetite

A patient's chart indicates a history of Meningitis. Which of the following would you not expect to see with this patient if this condition were acute? A. Fever B. Poor tolerance of light C. Increased appetite D. Vomiting

12-24 hours; Lessening disability

After a stroke has stabilized for __________ hours, interprofessional care shifts from preserving life to lessening ________ and attaining optimal functioning. The patient may be transferred to a rehabilitation unit, outpatient therapy, or home care based rehabilitation.

Global aphasia

Combined expressive and receptive aphasia. The nurse may need to assess the patient's swallowing test. Nursing interventions include repeating names of individuals and objects frequently, asking simple questions (yes or no), use picture board, provide adequate time to respond and be patient, only provide one instruction at a time, and do not complete their sentences for them.

20+ mmHg sustained

Elevated ICP is considered ________.

Brudzinski sign

Flexion of hip and knee when neck is flexed. This occurs with meningitis.

CT scan

How are intracranial hemorrhages diagnosed?

Monro-Kellie Doctrine

If one of the three components that make up the contents of the skull (CSF, Intravascular blood, and brain tissue) increases, another must decrease to maintain ICP.

CPP=MAP-ICP CPP= 92-10= 82

If your patient has an MAP of 92 and an ICP of 10, what is there cerebral perfusion pressure (CPP)?

Acetylcholine

In myasthenia gravis (MG), there is a decrease in the number of receptor sites of which neurotransmitter?

Subaute subdural hematoma

Intracrainal hemorrhage that is a slow bleed that occurs within 2-14 days of injury. It may appear to enlarge over time on a CT scan. These patient's are at an increased risk to re-bleed.

WBC count; oligoclonal banding

MS cerebral spinal fluid test will have an increased ____________________ count and the presence of ______________ ______________.

Left-sided brain damage

May occur with a stroke. It causes paralysis or weakness on the right side of the body, right visual field deficit, aphasia (expressive, receptive, or global), and altered intellectual ability. Patients may have slow and cautious behavior because they are usually aware of their deficits which may also make them anxious or depressed.

Non-infectious meningitis

Meningitis caused by brain injury (ex. basilar skull fracture or infection from ventriculostomy drain), cancer, lupus, or certain drugs (ex. immunoglobulins).

Parasitic meningitis

Meningitis that is contaminated to a person from an animal origin. It usually occurs when a human consumes infected meat or produce.

5-15mmHg

Normal ICP

Prestroke/Transient ischemic attack (TIA)

Often called a "mini-stroke," it is like a warning sign that a stroke will occur soon if no interventions are taken. Their effects are temporary and last usually less than 1 hour and most resolve within 3 hours but can last up to 24 hours. The patient should seek medical treatment right away to prevent stroke from occurring. Patients will typically be started on anti-platelet prophylaxis.

Kernig sign

Pain with extension of the leg that occurs with meningitis.

Nutrition for stroke patients

Patients who have had a stroke may have dysphagia, so they will need to have a swallow test done, diet accommodations made by a nutritionist, and oral pharyngeal exercises (PT). Patients with dysphagia are at an increased risk for aspiration pneumonia, dehydration, and malnutrition. Interventions to prevent aspiration include elevated HOB, chin tucked, start with ice chips, and perform oral care after food to prevent any pocketed food on numb side that the patient may not realize is present. It is important to ensure adequate intake by following the nutritionist's recommended kcal count and providing tube feedings or IV feedings (TPN) as needed.

Droplet; 72 hours

Patients with bacterial meningitis need to be placed on ___________ precautions until they have been on antibiotics for _______ hours.

Decorticate (flexor)

Posturing in which the arms are curled in like Cs towards the core. It indicates a problem with the cervical or spinal tract or cerebral hemisphere. It may occur in patients with increased ICP.

Decerebrate (Extensor)

Posturing in which the arms are out like e's. It indicates problems with the pons or midbrain. If this posturing is observed, call the code team and provider immediately. This can occur during increased ICP and indicates herniation and brain death are about to occur or are occurring.

Cerebral perfusion pressure (CPP)

Pressure needed to ensure that there is adequate blood flow reaching the brain. It is calculated by subtracting ICP from MAP (MAP-ICP). The normal range is 60-100 mmHg. If less than 50 mmHg, it is associated with ischemia and neuronal death.

Simple, comminuted, or compound skull fracture

Skull fracture that involves multiple linear fractures with fragments of bones. It is usually associated with direct, high momentum impact.

Receptive aphasia

Speech deficit caused by stroke that causes difficulty with comprehending speech.

Expressive aphasia

Speech disturbance caused by stroke that causes problems with expression.

Ischemic embolic storke

Stroke caused by a clot breaking free and traveling to a smaller vessel where it causes an occlusion and stops blood from getting to the brain. This accounts for 25% of CVA cases and usually occurs in patients with heart disease. These strokes have sudden onset with no warning signs. They can be temporary if clot breaks off and allows blood to go through the vessel.

Cerebral blood flow

The amount of blood in mLs passing through 100g of brain tissue in 1 minute. It is usually about 50 mL/min. The brain requires a constant supply of O2 and glucose, so maintaining this is very important.

Neurotransmission

Transmission of nerve impulses across neuronal synapses by neuro-transmitters which may be excitetory or inhibitory. It can affect intracranial regulation.

For disease: -women between 20-40 -some genetic component For relapse: -Exposure to viral illnesses or severe injury, if exposed seek treatment quickly. -Temperature extremes -Pregnancy (postpartum period) -Emotional stress

What are risk factors for Multiple sclerosis and its relapse?

CPP= MAP- ICP

What is the equation used to calculate Cerebral perfusion pressure?

Prevention

___________ is the best treatment for ischemic strokes.

Brain lacerations

A brain bleed caused by a bone fracture from a penetrating object such as a gun shot wound.

Glascow Coma Scale (GCS)

A client exhibiting an altered level of consciousness (LOC) due to blunt force trauma to the head is admitted to the ED. The nurse should gauge the client's LOC on the results of what diagnostic tool?

Basilar

A client in the emergency department has bruising over the mastoid bone and rhinorrhea. The triage nurse suspects the client has which type of skull fracture?

CT

A client is brought to the emergency department with symptoms of a cerebrovascular accident (CVA). The nurse would anticipate which diagnostic evaluation to be completed prior to initiation of treatment.

Determine whether the client is allergic to iodine, contrast dyes, or shellfish

A client with a head injury is scheduled for a computed tomography (CT) scan. What should the nurse do when preparing the client for this test?

Positive edrophonium (Tensilon) test

A client with a tentative diagnosis of myasthenia gravis is admitted for a diagnostic workup. Myasthemia gravis is confirmed by _______________.

Amytrophic Lateral Sclerosis (ALS)

A debilitating and usually fatal disease in which the patient usually dies within 2-5 years after diagnosis, but may live more than 10 years. Its etiology is unknown, but its pathophysiology is that motor neurons (tell muscles when to twitch/contract) run from the brain to the spinal cord degenerate and there is no longer a way to signal to muscles what to do. This leads to muscle atrophy and paralysis, loss of control of speech, writing, talking and even breathing. Eventually the diaphragm and chest wall are affected and cause respiratory failure. The onset of this disease is 40-60 years old and it is diagnosed by EMG or muscle biopsy. Clinical manifestations include extremity weakness leading to gradual loss of motor function, muscle wasting leading to atrophy and paralysis, fatigue, twitching, loss of ability to write, walk, talk, and then breathe (in that order). The patient will remain cognitively intact throughout this process so it is important that the nurse provides psychosocial care to help with depression and better facilitate communication and end-of- life care desires. There is no cure, only symptom management.

Parkinson's disease

A neuromuscular disease with gradual onset that is caused by a loss of dopamine production due to degeneration of substantia nigra which causes overstimualtion of acetylecholine. When dopamine cells die, movement is affected because dopamine (inhibitory) decreases and acetylcholine(excitetory) increases. Without dopamine, acetylcholine is not inhibited. This causes an imbalance and smooth muscle movement is lost. This disease is insidious and progressively debilitating. Classical symptoms of this disorder include tremors (pill-rolling), rigidity (stiffness), akenesia/bradykinesia, and postural instability. They may also have stooped posture, slow/shuffling gate without arm swing, and monotone speech with flat affect. There is no specific diagnostic test, diagnosis is based on symptoms and rule out of other causes along with a test with Sinemet. This test assesses the patient's response to Sinemet and if they have a response to the medication that reduces their symptoms, then this is considered a positive result for this disease.

C. Prevent a stroke by removing atherosclerotic plaques blocking cerebral blood flow

A patient having TIAs is scheduled for a carotid endarterectomy. The nurse explains that this procedure is done to A. Decrease cerebral edema B. Reduce the brain damage that occurs during a stroke in evolution C. Prevent a stroke by removing atherosclerotic plaques blocking cerebral blood flow D. Provide a circulatory bypass around throbotic plaques obstructing cranial circulation.

Guillain-Barre syndrome

An autoimmune disorder that attacks the nerves, causing demyelination and inflammation. Onset occurs as ascending parathesia (tingling/burning/numbness is felt in the lower extremities and moves up the body). The cause of this disorder is unknown, but it is usually triggered by a viral infection. Most people make a full recovery. Recovery is usually descending (from the face down). This disorder is diagnosed through CSF (lumbar puncture), nerve condition study, EMG, and MRI ( to rule out other causes of parasthesia) Clinical manifestations include parasthesia starting in the lower extremities, reduced muscle tone, NO reflexes, Ascending loss of motor function (due to demylination of nerves), and loss of autonomic functions (bradycardia and orthostatic hypotension occur and respiratory failure can occur).

Huntington's disease

An autosomal dominant genetic disease that causes repeated sequences of DNA and abnormal protein which results in abnormal moment problems and cognitive problems. Each generation will have a 50% chance of inheriting this disease and will be diagnosed earlier than the last. Onset usually occurs at ages 30-50 (post-child bearing). Genetic testing and counseling will help diagnose and prepare the patient for this condition. Genetic testing and symptoms are used to diagnose the disorder. This disorders causes deficiency in Acetylcholine and GABA which leads to excess dopamine and loss of motor control. Clinical manifestations include musculoskeletal and cognitive changes. Musculoskeletal changes include chorea (gross motor involuntary movement-wriggling/twisting), dramatic increase in kcal need due to constant chorea, tics, swallowing and slurred speech issues, and inability to walk in later stages. Cognitive changes include general decline (memory loss, decreased attention span, confusion, dementia, and issues making decisions, learning new information, answering questions, and remembering important information), emotionally labile, and depression and apathy r/t worsening of condition and deficits. Progression usually occurs slowly, but becomes severe in about 10 years and then death occurs in 10-20 years, typically from pneumonia or suicide. There is no cure, only symptom management.

Epidural Hematoma

An intracranial hemorrhage characterized by an initial period of unconsciousness and then a brief lucid interval followed by decreased LOC. The patient may also present with HA and N/V. This is a neurologic emergency! The patient needs to be sent to the OR right away for a rapid evacuation. The goal of treatment is to prevent cerebral herniation, manage increased ICP, and improve outcomes.

myasthenia gravis (MG)

Autoimmune disease that effects the skeletal muscles by creating antibodies that bind to nicotinic receptors, blocking Acetylcholine from being able to bind. This inhibits movement and leads to grave muscle weakness. The antibodies attack the acetylcholine receptors, resulting in decreased nere impulses that stimulate muscle movement. This disease is frequently associated with Thymus tumors or other over-action by the thymus gland. The thymus gland creates the antibodies, s the provider may decide to do a thymectomy to decrease antibody production and increase Acetylcholine. Clinical manifestations include fluctuating weak skeletal muscles that often result in ptosis and ocular issues but can also have an affect on facial muscles that make it difficult to swallow, speak, and eventually breathe. Limbs and trunk are less often affected. The patient will not experience any sensory loss, they will still have normal reflexes, and muscle atrophy is rare. This muscle weakness usually gets worse during the day and with repetitive movements, but improves with rest.

Intracerebral hemorrhage (ICH)

Bleeding into the brain tissue caused by rupture of a vessel that occurs during activity. HTN and cerebral atheroscleosis are the most common causes. There is a sudden onset of symptoms. The patient may complain of a terrible HA, changes in LOC, pupil changes, and other symptoms that are focal and size dependent. Call healthcare provider right away and if on any anticoagulants or Aspirin, stop them because the patient is actively bleeding. Progression occurs over minutes to hours because of ongoing bleeding. Prognosis is poor with a 30 day very high mortality rate of 40-80%. 50% of deaths occur within the first 48 hours. Quick intervention is needed, the patient will need to be sent to the OR.

Ischemic Thrombolytic stroke

Blood clot stops blood supply to an area of the brain, causing a stroke. Plaque builds up and slows blood flow then clot forms and narrows the pathway. This causes ischemia because blood cannot reach the brain. This kind of stroke makes up 60% of total CVA cases. 2/3 patients with this condition have hypertension (HTN) or diabetes melitis (DM). These strokes are often preceded by TIA. Collateral circulation may develop to allow for an alternative circulation path around the blocked artery/vein.

A. Nuchal rigidity B. Severe headache D. Photophobia

The nurse is assessing the lient with a tentative diagnosis of meningitis. Which findings should the nurse associate with meningitis? Select all that apply. c

Right-sided brain damage

Damage that may occur with a stroke. It causes paralysis or weakness of the left side of the body, left visual field deficit, spatial-perceptual deficits (increased fall risk), left sided neglect (Patient stops using left side of body because they don't see it), and increased distractibility. The patient may have impulsive behavior and poor judgement because they have a lack of awareness of deficits.

diabetes insipidus (DI)

Decreased production of ADH or decreased renal response to ADH. Manifestations include polyuria (increased urine output of 4-24 L/day), polyphagia (excessive thirst), low urine specific gravity low urine osmo with high serum osmo, increased serum Na, increased HR and low BP, irritability, and coma. They may also have decreased skin turgor, risk for fluid volume deficit, and dehydration.

Autonomic deficit

Deficit caused by stroke in which the CV and Respiratory system are affected. It is important to monitor this patient's ABCs (airway, breathing, and circulation). The patient may need O2, incentive spirometer, and continuous EKG monitoring.

Sensory deficit

Deficit caused by stroke in which there is sensory loss, loss of voluntary movements (Akenesia), impaired integrity of movements, and alterations in reflexes, and agnosia (loss of ability to recognize objects through loss of a sensory system (visual, auditory, or tactile)). The nurse should perform a musculoskeletal assessment for weakness, numbness, sensory perception, development of contractures, one-sided neglect, and vision changes/pupil changes. Nursing interventions include turning the patient q2h, passive ROM exercises, work w/physical and occupational therapy to increase muscle strength, and do NOT place hot pads directly on skin (they may not feel it) so put pillow case between it.

Multiple Sclerosis (MS)

Disease that affects communication of the brain by damaging myelin of neuron axons. Myelin protects, insulates, and ensures safe passage of electrical impulses down the axon. In this condition, an autoimmune response occurs and myelin is thought to be a foreign object. Myelin is damaged and demyelination occurs, causing distorted messages (not going fast enough or conveying what was sent or just not getting the message through). Patients with this condition have inflammation that occurs in the brain because of the body attacking myelin. Inflammation causes plaques/sclerosis to develop in the brain. Plaque damages the myelin sheath and eventually blocks impulse transmission. To be diagnosed with this condition, there are usually 2 or more different areas in the brain where plaque is present. The onset is gradual and it is insidious. It is a chronic, progressive, degenerative disorder of the central nervous system (CNS). Symptom burden varies widely from fever symptoms with little progression to rapid deterioration resulting in quadriplegia. Fatigue due to muscle tension and vision changes are common. Patients have periods of relapse and remission, sometimes they won't have the symptoms, but other times the symptoms may be exacerbated.

Anticholinergics- Triheyxphenidyl and Benztropine

Drug that decreases activity of Acetylcholine and is used to treat Parkinson's. Adverse effects include dry mouth, constipation, and urinary retention. This medication is contraindicated in patients with glaucoma. This drug should not be stopped abruptly, it can cause severe side effects.

MAO-B inhibitors- Selegiline and Rasagiline

Drug that increases levels of dopamine by stopping MAO activity in patients with Parkinson's. This drug also works to prolong half-life of levodopa. Patients on this medication should avoid tyramine containing foods such as aged cheese and smoked cured meats. Adverse effects include severe HA and HTN.

Apomorphine

Drug that is used during episodes of hypomobility for patients with Parkinson's. It can cause severe N/V, so it should be taken with an antiemetic drug (trimethobenzamide- Tigan) It is contraindicated in patients who take zofran because it can cause low BP and loss of consciousness.

Fingolimod

Drug that prevents lymphocytes from reaching the CNS and causing damage. Adverse effects include cardiac, infection, liver and kidney failure, and pregnancy (Cat. X).

Natalizumab and Alemtuzumab

Drugs used to treat more active and aggressive forms of MS. Thy have serious adverse effects including cardiotoxicity, leukemia, and infertility.

"off episodes"/ "off periods"

Episodes of hypomobility that can occur at the end of a dosing interval or at unpredicatvle time. Stalevo (combination carbidopa, lebodopa, and entacapone) can be given during these periods.

Contusion

Event resulting in bruising of brain tissue. It can continue to bleed or re-bleed. Focal and generalized manifestations may occur. Because there is some bleeding, swelling can occur and puts these patients at high risk for seizures we will need to monitor for seizures. Asses if they are on anticoagulants, because this increases their risk of hemorrhage.

Concussion

Event resulting in neuro change without specific brain damage resolves in 72 hours. Commonly occurs with sports injury. Post-concussion syndrome may occur within 2 weeks-2 months after injury and is residual effects for longer period of time. May cause continuous headache, fatigue, behavior changes, difficulty paying attention, and decreased short term memory. It may effect a patient's ability to do daily activities. It is good to have someone who can help monitor patient for changes in LOC and memory.

Diffuse Axonal Injury (DAI)

Event resulting in wide-spread brain damage. Axon swelling and disconnection occurs. This process takes 12-24 hours to happen. Signs and symptoms are similar to elevated ICP. These patients will be triaged to the ICU setting.

Paradoxic intoxication (dyskinesia)

Excessive dopaminergic drugs can lead to _____________ ___________.

Syndrome of Inappropriate Antidiuretic Hormone (SIADH)

Excessive production of ADH. Manifestations include low urine output, low serum Na and Cl, thirst, fatigue, decreased serum osmo, increased weight without edema, confusion and seizures. These patients will hold on to lots of fluids which can lead to fluid overload, weight gain, HTN, increased HR, and anorexia. The nurse should perform hourly VS, Neuro exams, and I&Os. Frequent labs should be performed. The patient may need fluid replacement with IV fluids (1/2 NS or 1/4 NS) and PO fluids if tolerated. The patient should avoid foods that cause natural diuresis, such as watermelon and caffeine. If this condition is caused by a problem that is neurological in origin, hormone replacement should be given as Desmopressin acetate (DDAVP). If this issue is renal in origin, thiazide diuretics and Na restrictions and Indomethacin (anti-inflammatory that increases renal response to ADH) can be given as treatment.

B. Time of which stroke symptoms first appeared

For a patient who is suspected of having a stroke, the most important piece of information that the nurse can obtain is: A. Time of the patient's last meal B. Time of which stroke symptoms first appeared C. Patient's hypertension history and management D. Family history of stroke and other CV diseases

Normal finding

The nurse is assisting with a lumbar puncture and observes that when the physician obtains CSF, it is clear and colorless. What does this finding indicate?

antidiuretic hormone (ADH)

Hormone that plays a major role in controlling the amount of water in your body and constriction of blood vessels. It works on the kidneys to control volume of fluid lost. The nurse should frequently assess VS, Neuro exams, I&Os, labs, and daily weights. Treatment involves restoring fluid and electrolyte balance, which will be done by administering hypertonic saline (3% or 1 1/2%) to help facilitate diuresis, fluid restrictions (800-1000 mL/day if Na is 125+), Lasix (only give if Na is 125+ or it can worsen electrolyte imbalances), and Declomycin (can block effects of ADH and promote diuresis). The nurse should provide regular oral care to patients especially if on fluid restrictions. We will treat underlying cause of this condition (except head injury), this includes tumors, drug side effects, and thyroid disorders.

-Computed tomography (CT) scan. Scan should be done and read in under an hour. Ischemic stroke may not appear on CT if it is under 3 hours old, but this still rules out hemorrhagic stroke. -CTA (CT angiography) can be done, but is more risky, but cause it can dislodge an embolus and cause vasospasm or further hemorrhage. It also uses contract media, which can cause an allergic reaction. -An MRI can also be used ad obtain greater specificity than CT, but it is very expensive.

How are strokes diagnosed?

1. Look for elevated Ach receptor antibody titer 2. Positive Tensilon test 3. Nerve conduction studies 4. Single fiber EMG

How is MG diagnosed?

-CSF test- increased WBC count and presence of oligocloanl banding -MRI- Assesses for plaque development

How is MS diagnosed?

Teriflunomide

Immunomodulary agent with antiinflammatory properties used to treat MS. Adverse effects include cardiac, infection, liver and kidney failure, and pregnancy (Cat. X).

Immunomodulators- interferon B-1a, interferon B-1b, and Glatiramer acetate

Immunomodulator drugs that are given intially to modify the disease progression and preent relapses.

Risk for falls

In reviewing a client's history and physical examination, a nurse finds that the client was found positive for ataxia during the physician's nuerological testing. Which nursing diagnosis will be a priority for this client?

increase fluids

The nurse is caring for a client who has developed SIADH. Would you restrict the fluids or increase the fluids?

Meningitis

Inflammation and infection of the meningeal tissue (protective layers that cover the brain). Spread depends on the type (fungal, parasitic, amebic, viral, or bacterial). At risk patients include patients with head trauma, immunocompromised, people who live in close quarters, and those with ventriculostomy drains. It is diagnosed with Lumbar puncture (LP) after a CT scan is performed to ensure that there is no brain herniation. It is important to also assess if the patient is on anticoagulants or has a CSF leak anywhere. This LP assesses the CSF. Normal CSF is clear, has no color, and no blood. CSF in a patient with meningitis is cloudy, has a positive gram stain with culture, and increased white blood cell count and protein. The patient will need to empty bladder before procedure, go into cannonball position, and puncture will hurt a bit.

subarachnoid hemorrhage (SAH)

Intracranial bleeding into the cerebrospinal fluid-filled space between the arachnoid and pia mater that is commonly caused by rupture of a cerebral aneurysm, trauma, or drug abuse. Loss of consciousness may or may not occur. Patient will complain of the worst headache ever, projectile vomit, and other symptoms are location and size dependent. It is often called the "silent killer" because it has a high mortality rate. Patients may die immediately or from continuous bleeding. Survivors often suffer significant complications and deficits.

Chronic subdural hematoma

Intracranial hemorrhage that occurs weeks or months after injury in which bleed is still occurring. This kind of bleed is more common in older adults and there is an increased risk of misdiagnosis. The patient will present with focal symptoms. Treatment includes surgical evaluation for evacuation of the clot. These patients are at increased risk for re-bleed.

Acute Subdural Hematoma

Intracranial hemorrhage within 24-48 hours of injury. Symptoms are r/t increased ICP and include decreased LOC, HA, and Ipsilateral pupil dilation (one side dilated different from other) or fixed pupils if severe. Patients with this kind of hemorrhage are at an increased risk of re-bleed.

Basilar Skull Fracture

Linear fracture (No movement of bone fragments) with manifestations that include "raccoon eyes" (bruising around the eyes), Battle's sign (post-auricular bruising), rhinorrhea/otorrhea (CSF leaking out of ear or nose- can be differentiated from drainage through a dextoxtic/Testape test that will be positive for glucose if it is CSF or by Halo's sign), loss of consciousness followed by period of normal LOC and then loss of consciousness again, and N/V, Hearing and vision changes, or facial numbness may occur depending on what area of the brain was effected. It is diagnosed using a CT scan. The nurse should take measures for patients leaking CSF including elevating the HOB, do not put anything into their ears or nose (a loose collection pad can be used), no sneezing or blowing nose, no NG tube, and no nasotracheal suctioning. These patients are at risk for compilations including increased ICP, cranial nerve damage (visual changes, tinnitus, hearing loss, and facial paralysis), and infection and meningitis.

-Changes in CSF Volume -Changes in intracranial blood volume - Changes in tissue brain volume These changes may help, but the body can only compensate so much. If volume continues to increase and ICP continues to increase, then decompensation (herniation or ischemia) will occur.

List some normal compensatory adaptations to increased ICP.

1. Perfusion 2. Neurotrasmission 3. Pathology

List three things that affect intracranial regulation.

Bacterial Meningitis

Meningitis that is a medical emergency and is very contagious and has a rapid onset.The patient may have fever, severe HA, N/V, Nuchal rigidity (neck stiffness), photophobia, altered LOC, Red Macular rash (use tumbler test- puse drinking glass on rash to see if it fades away or not-rash of meningitis will NOT blanche), Kernig sign (pain with extension of legs), Brudzinski sign (flexion of hip and knee when neck is flexed), Cranial nerve damage, and patient history. It may be caused by Neissera meningitides, streptococcus pneuomoniae and group B streptococcus, Haemophilus influenzae type B (Hib), Listeria monocytogenes (usually found in contaminated food). Health promotion includes getting vaccines for neisseria, strep, and Hib and prophylactic treatment for patients with close contact. Treatment is antibiotics and symptomatic treatment using anti-pyretics for fever and anti-seizure meds/seizure precautions for seizures that may be caused by swelling.

Fungal meningitis

Meningitis that is contaminated to a person from soil and bird droppings. People with weakened immune systems are more likely to get it.

Infectious meningitis

Meningitis that is fungal, parasitic, amebic, viral, or bacterial.

Amebic meningitis

Meningits that is contaminated to a person from inhalation of contaminated water (usually through the nose).

Scalp Laceration

Minor head injury that involves external head trauma and causes profuse bleeding. Complications of blood loss and infection may occur from this injury.

hemiplegia/hemiparesis

Motor loss that can occur as a result of stroke. It is characterized by weakness or paralysis on one side of the body.

Levodopa with carbidopa (Sinemet)

Primary drug treatment for Parkinson's disease. This drug is the precursor of dopamine and can cross the BBB and is then converted to dopamine in the basal ganglia. Sinemet inhibits breakdown of dopamine in blood so that this drug can enter the brain and act as dopamine. It can take up to 3 weeks to see decreased symptoms of Parkinson's. Adverse effects of these drugs include body fluids turning a dark color, nausea, and involuntary movements (dyskenisia). The patient should avoid protein rich foods when taking Sinemet because it can decrease its efficacy. These drugs could wear off after a few years of therapy. Usually Sinemet is added to treatment when symptoms become moderate to severe. Prolonged use of Sinemet often results in dyskinesia and if it occurs, physicians may prescribe a drug holiday and add another med. "Off/on" periods may occur where the medication may stop working spontaneously and then regain its efficacy-it is unpredictable.

Myasthenic Crisis

Problem in which a patient with MG is not taking enough Anticholinesterase. This will result in respiratory distress, increased HR and BP, and decreased cough and gag reflex. When given the Tensilon test, the patient will start to feel better. Causes of this condition include infection, hormonal changes, emotional upset, or alcohol. Treatment includes Tensilon to improve symptoms and then increase Ach slowly by restarting Anticholiesterase. Supportive care should be taken to maintain airway, respiratory function, and hemodynamics.

Cholinergic crisis

Problem in which the patient has too much Anticholinesterase. This causes increased weakness, difficulty chewing and swallowing, and N/V/D. The Tensilon test will cause these symptoms to worsen. Causes of this condition include accidental OD of Anticholinesterase or spontaneous remission of MG. Treatment is to give the patient Atropine and decrease the patients Ach levels by holding the medication.

Therapeutic plasma exchange (Plasmapheresis)

Procedure used to treat MS in which plasma is taken out of the patient's body and separate it into the blood components then try to remote the autoimmune antibodies the patient is developing.

Ablation surgery

Procedure used to treat Parkinson's in which the area of the brain affected by Parkinson's disease is located, targeted, and destroyed. It destroys tissue that produce abnormal chemical or electrical impulses leading to tremors or other symptoms.

Stroke/Cerebral vascular accident (CVA)

Sudden death of brain cells due to lack of oxygen when blood flow to the brain is impaired by blockage or rupture of an artery to the brain. This can cause disabilities such as hemiparesis (paralysis or weakness of one side of the body), inability to walk, complete or partial dependence for ADLs, aphasia, and depression. Prevention is key, altering modifiable risk factors such as dyslipidemia, uncontrolled HTN, CV disease, diabetes, obesity, poor diet, smoking, excessive alcohol consumption, physical inactivity, lifestyle, and chronic atrial fibrillation. Patient education and the use of antiplatelet drugs (aspirin, clopidogrel/Plavix, warfarin/coumadin) also help prevent this.

B. Pain on extension of legs

The client with suspected meningitis is admitted to the unit. The doctor is performing an assessment finding to determine meningeal information. A positive Kernig's sign is charted in the nurse notes: A. Dizziness when charging positions B. Pain on extension of legs C. Pain when the head is turned to the left side D. Nuchal rigidity on the flexion of neck

B. Had a serious head injury four weeks ago

The client, diagnosed with an ischemic stroke, is being evaluated for throbolytic therapy. Which assessment finding should prompt the nurse to withhold throbolytic therapy? A. Brain CT scan results show no bleeding B. Had a serious head injury four weeks ago C. Has a history of type 1 diabetes mellitus D. Neurological deficits started 2 hours ago

C. Expressive aphasia

The client, who had a stroke, follows the nurse's instructions without problems, but an attempt to verbally respond to the nurse's question was garbled. The nurse should identify that the client has which type of aphasia? A. Receptive aphasia B. Global aphasia C. Expressive aphasia D. Anomic aphasia

Glasgow Coma Scale (GCS)

The gold standard for continuous LOC assessments. It involves assessment of the patients ability to open their eyes, verbal response, and motor response. Higher scores indicate higher levels of brain functioning. The highest score is a 15 and lowest is a 3.

Deep brain stimulation

The most common surgical treatment for Parkinson's. It is a last resort after medication stops working. In this procedure, a thin electrode is placed in the thalamus or subthalamus and send in an electric current to interfere with tremor cells. This method is preferred because it is reversible and programmable. This decreases neuronal activity produced by dopamine depletion to improve motor function and reduce dyskinesia and medications.

C. Develops decreased LOC and a headache within 48 hours of a head injury

The nurse is altered to a possible acute subdural hematoma in the patient who A. Has a linear skull fracture crossing a major artery B. Has focal symptoms of brain damage with no recollection of a head injury C. Develops decreased LOC and a headache within 48 hours of a head injury D. Has an immediate loss of consciousness with a brief lucid interval followed by decreasing LOC.

BEFAST: Balance Eyes Face Arms Speech Time

The nurse is assessing a client with a suspected stroke. What acronym (assessment findings) are most suggestive of a stroke?

Nuchal rigidity and headache

The nurse is assessing a client with meningitis. Which signs would the nurse expect to observe?

Falls and motor vehicle accidents

The two most common causes of head injury include _______ and _______________________________________.

Pathology

Things that can impact intracranial regulation, such as brain tumors, certain degenerative diseases and inflammatory conditions. This includes meningitis, Parkinson's, and Huntington's.

Unilateral neglect

Visual, hearing, or sensation loss on one side of patients who have had strokes. Interventions include to approach from the patient's unaffected side, place essential items on unaffected side, tough the patient before speaking so we don't scare them, protect affected side from any other injury. The patient should be taught to consciously attend to affected side. Initially, the nurse should accommodate the deficit by placing objects on unaffected side, but gradually the nurse should place objects on affected side as patient becomes adept at conscious attention.

1. Safety- fall, skin, and aspiration precautions 2. Nutrition- high protein, high calorie diet. May need food to be cut up and be on soft or thick diet. The nurse will need to assist with feeding because of chorea. It is important to be patient. 3. Communication- consult with speech therapy, find alternate use of communication (ex. cards, blinking). 4. Confusion and impaired social interaction- reorient patient each time you see them, talk to family, friends, and volunteers to have them sit and talk with patient. 5. Emotional support through genetic counseling for patient and family.

What are nursing actions that should be taken for patient's with Huntington's disease?

For disease: women between 20-40; some genetic component For relapse: -Exposure to viral illness or severe injury, if exposed, seek treatment quickly -temperature extremes -pregnancy (in post-partum period) -emotional stress

What are risk factors for Multiple sclerosis?

Preserve life, preventing further brain damage, reducing disability

What are the goals for interprofessional care of ischemic stroke?

-Slow progression (disease modifying therapies) -Treat attacks (relapse) -Manage symptoms

What are the goals of medication for patients with MS?

1. Evacuating 2. Coiling- acts as clot in bleeding area 3. Clipping of Aneurism (so it won't bleed anymore) NEVER give APA, tPA, Heparin, or Warfarin to hemorrhagic stroke patients. Goal: Control HTN, will help decrease bleeding; systolic pressure needs to be less than 160.

What are the invasive 3 "ings" of hemorrhagic stroke medical treatment?

1. glutamate antagonist- slows progression of ALS 2. Baclofen- treats bladder spasms 3. Valium- treats muscle spasms 4. Antibiotics for UTI, Pneumonia, etc. -These patients usually eventually die from pneumonia.

What are the medications used to manage the symptoms of ALS?

-Exercise/ROM -Energy conseration- easier to put on clothes; promote grouping care together and allowing rest periods - Encourage fluid intake -Prevent UTIs -Encourage nutrition - Water therapy

What are the nursing interventions for MS?

1. Isolation-droplet precautions (until they have been on antibiotics for 72 hours). 2. Some types of meningitis have to be reported to public health department (ex. Neisseria bacterial meningitis has to be reported withing 24 hours of diagnosis) 3. Continuously monitor neuro status and notify provider of changes 4. Elevated HOB in case the patient has increased ICP. 5. Encourage rest. 6. Symptom management (fever, pain, seizures, rest, decreased exposure to bright light, and fluid and electrolyte management).

What are the nursing interventions for bacterial meningitis?

1. Male age 40-70 2. Genetic factors 3. Environmental factors-increased use of well water, pesticides/herbicides, industrial chemicals, copper, and lead 4. Chronic antipsychotic medications-regalaln, reserpine, methyldopa, litium, halodol, and chloropromazine 5. Elicit drugs such as amphetamines and methamphetamines. In cases caused by drugs, if you stop the drugs, symptoms sometimes disappear.

What are the risk factors for Parkinson's?

Vision changes (blindness in one eye, eye pain, diplopia/blurred double vision, color distortion in red or green) (usually occurs with onset of the disease), pain/paresthesia, fatigue, hearing and balance, dysphagia, dysarthria ataxia and muscle weakness, muscle spasicity, bowel dysfunction, bladder dysfunction, sexual dysfunction, and cognitive changes (depression, dementia, and pseudobulbar affects-uncontrollable crying or laughing).

What are the signs and symptoms of MS?

-Rheumatic disease and A-fib prevention with blood thinners, exercise, and healthy diet.

What can be done to prevent embolic ischemic strokes from occurring?

-Control HTN and diabetes -ASA prevents clot formation -Encourage exercise -Smoking cessation -Limit alcohol intake -diet modifications

What can be done to prevent throbmolytic ischemic strokes from occurring?

-Adjustment in diameter of blood vessels -Ensuring consistent cerebral blood flow - Only effective if mean arterial pressure (MAP) of 70-150 mmHg (must be maintained to get blood to the brain).

What happens during autoregulation?

Adequate cerebral oxygenation and perfusion are maintained and there is no secondary cerebral ischemia.

What is the focus of nursing care for patients with an intracranial hemorrhage?

Increase functioning ability and decrease effects of Parkinson's and minimize long term effects.

What is the purpose of giving medication to patients with Parkinson's?

Tissue plasminogen activator (tPA) Screening for tPA eligability: -rule out hemorrhagic stroke -time of symptom onset-tPA must be given in the first 3 hours -History- surgery, head trauma/stroke in the past 3 months, GI bleed within 2 days, major surgery within 14 days. Must maintain an MAP of greater than 65

What medication is used as pharmacological treatment for ischemic stroke? What screening must be done to determine eligibility for this medication?

1. Anticholinesterase- increases Ach by blocking its break down and helps counteract effects of antibodies. 2. Corticosteroids (prendisone)- Decrease inflammation and works as an immunosuppressant 3. Immunosuppressants (Azathioprien, Mycophenolate, and Cyclosporine)

What medications are used to treat MG?

1. Tetrabenazine- only drug that helps with chorea and decreases dopamine. 2. Antipsychotics (Valium, Haldol, Respradol) 3. Muscle relaxants (Klonopin)

What medications do patients with Huntington's disease take to manage symptoms?

1. Nutritional support with tube feedings and fluid support 2. Musculoskeletal interventions- prevent falls and contractures- perform passive ROM exercises 3. Aspiration precautions 4. Pain management 5. Skin assessment 6. Promote independence 7. Psychosocial- Depression, communication (may need to use communication board), advanced directives and end-of-life considerations.

What nursing care can be provided to a patient with ALS?

1. Aspirin to prevent future clots 2. Ticlopidine (Ticlid) 3. Clopidogrel (plavix)

What pharmacologic interventions can be used for TIA management?