Alzheimer's Disease & Stroke!!!

Multiple sclerosis (Assessment)

(1) At 1st Vague symptoms/Later (2)Weakness or clumsiness arm/leg (3)Blurred vision *DIPLOPIA (double vision), (4)Spasticity, ataxia (5) numbness/ tingling of an arm or a leg (Paresthesia) (6) An intention tremor slurred, hesitant speech (scanning speech) (7) Vertigo, tinnitus, decreased hearing (8)Chronic neuropathic pain (9) Dysphagia (10) Bowel/bladder (11) Emotional changes (Mood swings) (12) Cognitive changes (Memory loss - late) difficulty concentrate, impaired judgment *nystagmus (involuntary movement of the eyeball) *blindness. weakness, clumsiness progresses to ataxia (motor incoordination) or paraplegia (paralysis of both legs)

(III) Oculomotor

(III) Oculomotor, contraction of iris & eyes muscles (eye movement) In a dark room, shine a bright light in each pupil; ask client to look at a near & far object Ask the client to follow an object you move in horizontal, vertical & oblique directions Normal; eye movement is coordinated in all directions

hemorrhagic stroke (Know the difference)

*Hemorrhagic strokes occur when a cerebral blood vessel ruptures & blood is released in brain tissue When a hemorrhagic stroke occurs, blood leaks from intracerebral arteries. The collection of blood adds volume to the intracranial contents, resulting in elevated pressure. predisposition factor; UNCONTROLABLE HBP Hemorrhagic strokes are more common in particular areas of the brain such as the cerebellum, the structure that facilitates balance, coordination & the brain stem, which controls breathing, BP, & heart rate. Various factors increase the risk for a CVA. *Common causes of cerebral hemorrhage are hemorrhagic disorders as leukemia & aplastic anemia, severe hypertension, brain tumors, blood thinner

The two main types of strokes (Ischemic/Hemorrhagic, about 80% are ischemic variety)

*Ischemic strokes occur when a thrombus or embolus obstructs an artery carrying blood to the brain *When ischemic strokes occur, glucose & O2 to brain cells are reduced. Brain cells & tissue die from anoxia lack of O2 & lower pressure perfusion (lead death) Denise; *Predisposition factor for ischemia is Atrial fibrillation (AF), rapid heart rate cause poor blood flow *Atherosclerosis/ arteriosclerosis are major contributors to formation of thromboembolic & subsequent CVAs.

Cerebral Hematomas

A cerebral hematoma is bleeding within the skull. The accumulation of blood forms an expanding lesion *Those receiving anticoagulant therapy & those with underlying bleeding disorder, as hemophilia, thrombocytopenia, leukemia & aplastic anemia are at high risk for CH. causes; head trauma Or cerebral vascular disorders. The types of hematomas are *Epidural, Subdural *Intracerebral hematoma

Diagnostic finding (meningitis)

A lumbar puncture *Samples of CSF are obtained. If the meningitis is bacterial CSF appears cloudy. The CSF pressure is elevated, glucose concentration is decreased *protein is elevated WB & RBC counts ^ *Culture & sensitivity studies are performed to identify the specific causative bacteria. If meningitis is viral, culture & sensitivity studies are negative. C &S, CT scan, blood culture, complete blood cell count (CBC)

Alzheimer's disease (most common cause of dementia)

A progressive, deteriorating brain disorder. Two types: early onset 30-60 yrs of age & late onset; after 60yrs (more common) Early-Onset; increase risk, first-degree relative(mom/dad) with AD *Inherited genetic abnormalities 4 pathologic changes in brain (1)Decreased cortex size (2)Deficient acetylcholine (3)neurotic plaques (4) Neurofibrillary tangles *Amyloid plaques are aggregates of misfolded proteins that form in the spaces between nerve cells. *poor sense of smell is one of the earliest signs of AD

stroke (cerebrovascular accident [CVA])

A prolonged interruption of blood flow through an arteries that supply the brain. Consequences!! *Brain & cerebral nerve cells are extremely sensitive to a lack of oxygen; if the brain is deprived of oxygenated blood for 3-7 min during a stroke, they both begin to die. Once these cells are destroyed, the outcome is irreversible

Nutrition for Alzheimer's

AD can devastate nutritional status. Forgetfulness, alterations in smell, taste & decreasing ability to self-feed impair intake. Weight loss is common. Choking if client forgets to chew food thoroughly or hoards food in his or her mouth. Increased agitation significantly increases calorie requirements. Nutritionally dense foods that are easy to consume, such as finger foods & liquid supplements, help maximize intake. Minimize distractions at meals & offer one food at a time to avoid overwhelming the client. Clients in the later stages of AD may be unable to swallow or may not know what to do when food is placed in their mouths. *percutaneous endoscopic gastrostomy tube feedings may be necessary

Multiple Sclerosis (MS)

Achromic, progressive disease of the peripheral nerves. *Disseminated Demyelination of neurons of brain & spinal cord Its onset is in young adulthood, early middle age & greatest between 20/40 yrs age (affect = men/women) MS is more common in northern temperate zones than in warm climates. *Periods of remission & exacerbation *Myelin acts as an insulator, enabling nerve impulses to pass along a nerve fiber. Loss of myelin & subsequent degeneration & atrophy of nerve axons interrupt transmission of impulses along these fibers clients experience worsening symptoms. *As the disease progresses, many complications such as pressure ulcers, cachexia, deformities & contractures develop. Pneumonia, brought about by limited activity, shallow breathing, and general debility, is often the immediate cause of death.

Care for strokes (Nursing)

Administer medications as directed & understand the potential side/ adverse effects. Implement eating & swallowing techniques that reduce the potential for aspiration *Heimlich maneuver to clear the airway if client cannot speak or breathe after swallowing food. *follow-up care with speech pathologist/dietitian. Contact community resources as medical supply companies that rent or sell special care devices as a hospital bed, bedside commode, walker, or tripod cane. *Remove throw rugs, clutter & electrical cords from the client's home environment to reduce potential for falls. Perform regular exercises, change the client's position frequently & apply braces or splints designed to maintain extremities in proper anatomic position.

Postoperative Care (cerebral Hematoma)

After surgery, places client in supine position with head slightly elevated or side-lying position on unaffected side & perform post-operative/neurologic assessment every 15 to 30min. Maintain a neurologic flow sheet to compare trends in assessment findings. *Edema around eyes (periorbital edema) Make examination of pupils difficult during the immediate postoperative period. *Ecchymosis can also be present Remove antiembolism stockings briefly every 8hrs & reapplies them. Important to monitor Temp closely because hyperthermia ^ brain metabolism & ^ the potential for brain damage. Elevated temp must be relieved with antipyretic & other measures. Observes client closely for ^ ICP. Restricts fluids to control cerebral edema & increase cerebral perfusion.

Discuss the impact of CVA on a person's life

Although the site of the cellar damage is located in the brain the consequences are widespread survivors have permanent disabilities *permanent neurologic deficiency have profound physical, emotional & financial effect on client/family *Impaired speech, restricted physical abilities, weakness or paralysis of limbs on one side of the body, difficulty gripping or holding things & slow ability tocommunicate

Alzheimer's diseases (stages)

Alzheimer's disease stages can occur at different rates symptoms develop slowly over yrs. a poor sense of smell is one of the earliest signs of AD's 3 distinct stages are; (1) Preclinical—period when amyloid plaques are accumulating & nerve cell changes are occurring, but there are no clinical symptoms of AD (2) Mild cognitive impairment—time when memory problems are noticed but not serious enough to interfere with independent living (3) Alzheimer's dementia—the point at which there is significant cognitive decline, as difficulty recalling words, trouble learning new information, difficulty recognizing familiar faces, impaired reasoning, judgment/ problem solving These abnormally proteins play a central role in AD. The amyloid plaques firs develop in the areas of the brain concerned with memory & other cognitive functions (part 1) *poor sense of smell is one of the earliest signs of

Nursing Management MS

Assess physical & emotional status Identify visual problems Listen to the client's speech, may be slurred & difficult to understand. using a language board or other assistive device if communication is severely affected. Adaptive devices for self-care needing may be helpful if the client has hand tremors; the client's weight should be assessed regularly to ensure that there is no significant weight loss. Eventually, the client's food may require blenderization if swallowing is impaired If ambulation is impaired, the client may find a wheelchair or other device to be useful temporarily. Safety is a real issue for clients as their mobility becomes less stable. I identify techniques for managing constipation with high-fiber food & fluids. Bladder elimination may be controlled with intermittent catheterization, inserting an indwelling catheter, or creation of a cystostomy. skin care & position changes are implemented to avoid pressure sores. Instruct client concern drug therapy, which often facilitates a remission of unknown duration or reduction in the rate of relapse Client/family may refer to social Security disability benefits.

Diagnostic finding (Parkinson's disease)

Based S/S & neurologic examination. No specific tests! *MRI/CT; shows unusual clumps of protein "Lewy bodies" found in brain *Drug therapy goal: prolong independence; selegiline (Eldepryl), levodopa (Larodopa) • Physical therapy, occupational therapy, client & family education; nutritional counseling • Surgical Management • Stereotaxic pallidotomy, deep brain stimulation (DBS)Rehabilitation measures such as physical therapy, occupational therapy, counseling for drug therapy. *Stereotaxic pallidotomy is a surgical procedure performed in selected cases. The procedure destroys a part of the globus pallidus to eliminate or reduce tremor, stooped posture, shuffling gait & stiff movement. Some clients with Parkinson's disease have obtained relief of symptoms through deep brain stimulation (DBS). DBS involves the implantation of a neurostimulator that works like a pacemaker for the brain.

intracerebral hematoma

Blood collects within the brain. *Bleeding within the brain that results from an open or closed head injury or from a cerebrovascular condition such as a ruptured cerebral aneurysm. Bleeding ^ volume of brain contents & ICP, which disrupts blood flow & causes the brain to become ischemic & hypoxic. *Unrelieved ^ ICP causes the brain to shift to lateral side ( UNCAL HERNIATION) or herniate downward through the foramen affect the vital centers for respiration, heart rate, BP & cranial nerve functions. Death occurs if the symptoms are not recognized & bleeding is not controlled. *S/S; increase ICP, Headache, vomiting, seizures, posturing, hyperthermia, irregular breathing.

Diagnostic Findings CVA

CT scan, MRI differentiates a CVA from other disorders, such as a brain tumor or cerebral edema, shows; size location of the infarcted area. *Transcranial Doppler ultrasonography determines the size of intracranial vessels and the direction of blood flow and locates the obstructed cerebral vessel. *Single-photon emission computed tomography (SPECT) identifies cerebral blood flow. *An EEG reveals reduced electrical activity in the involved area but is not a specific diagnostic test for a CVA. *Lumbar puncture, If subarachnoid bleeding has occurred, the CSF will be bloody. *Cerebral angiography shows displacement or blockage of cerebral vessels.

Treatments (Medical/Surgical )

CVA is a medical emergency (treatment varies cause) Tissue plasminogen activator (TPA), a thrombolytic agent, has been found to limit neurologic deficits when given within 3 hours after the onset of an ischemic CVA. NOT for hemorrhagic CVAs, as is anticoagulant therapy. Several neuroprotective agents such as NMDA receptor blockers, calcium & glutamate antagonists, antioxidants are nearing completion in clinical trials in US. Hypothermia also is being used to protect damaged cells by reducing their metabolic need for oxygen. If atherosclerosis of carotid artery is the cause, "a carotid endarterectomy is need" A ruptured cerebral aneurysm is treated surgically. In many cases, treatment is supportive because medical or surgical interventions cannot repair damaged brain tissue. The best treatment available involves an intensive medical program aimed at rehabilitation & the prevention of future CVAs

Parkinsonism's Disease

Deficiency of the neurotransmitter dopamine. dopamine depletion *Causes; Unknown *exposure to environmental toxins such as insecticides, herbicides *Others: sequelae of chronic traumatic encephalopathy from head injuries or blows to the head & encephalitis *Manifestations of the disorder progress so slowly that years may elapse between the first symptom& diagnosis. The symptoms initially are unilateral, but eventually, whether quickly or slowly, become bilateral.

Pathophysiology (Etiology of multiple sclerosis)

Causes; Unknow Virus or Autoimmune disorder that trigger by defective genes, inflammation involved in controlling the immune system. or a link between a distorted gene that causes vitamin D deficiency and MS. *MS is characterized as a demyelinating disease, causes permanent degeneration & destruction of myelin sheath. *As the disease progresses, many complications such as pressure ulcers, cachexia, deformities & contractures develop. Pneumonia, brought about by limited activity, shallow breathing, and general debility, is often the immediate cause of death.

Strokes (S&S)

Clients experience one or more TIAs (mini stroke) days, weeks, or years before a CVA, other may be suddenly NO warnings! Signs of an impending CVA: Numbness or weakness of one side of the face, arm, or leg *Mental confusion *Difficulty speaking or understanding *Impaired walking or coordination *Severe headache

Medical Management (TIA)

Control BP *lose excess weight stop tobacco *alcohol use • Manage atherosclerosis cardiac dysrhythmias; *cholesterol-lowering drugs, prophylactic anticoagulant or antiplatelet • Aspirin, clopidogrel (Plavix), warfarin (Coumadin) • Diabetic education *Surgical; Carotid endarterectomy • Percutaneous transluminal angioplasty & stent placement *Facial drooping, Arm weakness, speech difficulties & time. *Fast Acronym (for a stroke) face; is it drooping *Arms; can you raise both? *Speech; is it slurred or jumbled? *Time; call 9-11 right away *Older adults may ignore the symptoms of a TIA, attributing them to part of the normal aging process

Dementia (more common in older irreversible/not normal)

Decline in memory, thinking & mental function that affect individual's daily life. Various disorders are characterized by dementia: Alzheimer's disease (AD), followed by cerebrovascular disorders & Parkinson's disease. In contrast to delirium, dementia is manifested by a gradual, irreversible loss of intellectual abilities. Dementia display S/S similar to Delirium but differences the following; (1) ONSET; gradual (2)Presentation; alert/attentive (3)Couse; stable, progressive deterioration & extended (4)Duration; permanent (5)treatment symptomatic or supportive (6) Outcome; INCULABLE

Older adults delirium

Delirium in older adults may occur for infections as pneumonia or urinary tract infections or from fecal impaction. *Delirium may present as hyper or hypoactive! *Hyperactivity; picking at bedcovers or clothing, nervous behaviors *Hypoactivity; refusing to make eye contact or verbal exchanges, lethargy. Cognition changes such as delirium must be thoroughly documented regarding onset, course & relationship to any medication (including anesthesia)

Assessments findings

Depend on rapid severity of neurologic changes, location, rate of bleeding, size of the hematoma & effectiveness of autoregulation, the brain's ability to provide sufficient arterial blood flow despite rising ICP. MRI/ CT scan show location & shifts in cerebral tissue. *Medical; in some cases body walls off & absorbs a subdural hematoma with no treatment However, a rapid change in LOC/ signs of uncontrolled ^ ICP indicates a surgical emergency

Surgical (for cerebral Hematoma)

Drilling holes in skull, known as trephining, relieving pressure, removing clot & stop bleeding. If bleeding cannot be located by burr holes, more invasive surgery is performed. *Epidural hematomas require more prompt intervention COZ the rate of bleeding is greater from an arterial bleed than from a venous bleed. *Intracranial surgery; consist of 3 procedures craniotomy, craniectomy & cranioplasty! *craniotomy; surgical opening of the skull to gain access beneath cranial bones. Its performed to remove a blood clot or tumor, stop intracranial bleeding, or repair damaged brain tissues or blood vessels. *craniectomy; removal of a portion of cranial bone. Cranioplasty; repair defect cranial bone The portion of bone removed during craniectomy may be implanted in the client's abdomen awaiting later replacement. A metal, plastic plate or wire mesh is used to replace the removed bone or to reinforce a defect in a cranial bone

Diagnostic Findings (multiple sclerosis)

Early s/s vague & some are temporary. MRI- Brain and spinal cord may or may not show plaques (protein) *Lumbar puncture CSF Shows; Increase gamma immunoglobulin G bands, described Oligoclonal bands The bands appear separated rather than homogeneous, which is the normal finding. *WBC increase CT-Atrophy-late A CT scan and MRI may or may not disclose lesions in the brain's white matter.

Alzheimer's disease (Diagnostic/medical management)

Electroencephalography; detect slower-than normal brain waves CT; show cerebral cortex shrinking not on early. PET/ MRI; provide structural/metabolic information about the brain *Medical; NO cure; supportive treatment *Drug; folic acid supplements; B12 for impair neuro *Antidepressants *Tranquilizers Maintaining client's independence in home environment as long as possible; refer to ECF if/when appropriate *Nursing Goal; help client & caregiver maintain highest possible quality of life by supporting mental, physical functions & ensuring safety. Need home health care nurse. To assess: client safety; caregiver burden

medical care for Seizures

Emergency care • Status Epilepticus DRUGS • Rapid acting IV antiseizure .Lorazepam(Ativan) diazepam (valium) • Short acting so follow with long acting *phenytoin or phenobarbital • Anticonvulsant drugs: phenytoin(Dilantin), phenobarbital, carbamazepine (Tegretol), IV barbiturates or diazepam (Valium) NURSE; Oxygen & airway • Bed in low position • Documentation of the situation that proceeded the seizure to assist in identifying any precipitating factors or aura, duration of seizure, parts of the body involved • V/S, oxygen saturation, capillary blood glucose level

Right Sided hemiplegia (Stroke on the left side of Brain affect the right side)

Expressive aphasia Receptive aphasia Global aphasia Intellectual impairment Slow/cautious behavior Defects in right visual fields Short retention of information Require frequent reminding to complete tasks Difficulty with new learning Problems with abstract thinking, such as conceptualizing & generalizing

Nursing Diagnosis

Risk for Ineffective Breathing Pattern related to weakening of muscles for respiration • Encourage client to deep breathe several times. • Place client in a Fowler's position support the arms. * Impaired Physical Mobility related to diminished muscle strength & inactivity • Provide rest between bathing, eating, & ambulating. • Baclofen (Lioresal), Dantrolene (Dantrium) for muscle spasticity & rigidity (relax muscles) * NUTRITION; Client With a Neuromuscular Disorder & muscle wasting benefit from an increased protein intake; commercial supplements (thick liquids, fortified puddings/gelatins) are tasty & easy options. Semisolid foods as puddings/mashed potatoes are easier to swallow than thin liquids or a regular diet. Gastrostomy feedings are usually the best route for clients who require long-term enteral nutritional support.

meningitis (S/S)

Headache, fever & nuchal rigidity (pain/stiffness of the neck, inability to place the chin on the chest). N/V photophobia (aversion or sensitivity to light), restlessness, irritability, seizures *Severe irritation of the meninges causes opisthotonos; extreme hyperextension of the head/arching of the back. A positive Kernig's sign (inability to extend the leg when the thigh is flexed on the abdomen) & a positive Brudzinski's sign (flexion of the neck produces flexion of the knees and hips) client with meningococcal meningitis may have multiple, small to large petechiae that spread over the body, giving the appearance of a rug burn. The petechiae intensify & coalesce (fuse together) to resemble purpura or ecchymoses due to a secondary disturbance in blood coagulation from thrombocytopenia or disseminated intravascular coagulation. Those with viral meningitis develop a nonspecific maculopapular rash

Nursing Diagnosis for Parkinson's

Impaired Physical Mobility & Self-Care Deficit related to muscular rigidity, tremors & dementia • Assist with ambulation. • Minimize fatigue; provide rest periods. • Nursing Diagnosis: Impaired Verbal Communication related to inability to articulate words • Anticipate client needs • Reduce environmental noise. • Ask client to speak slowly.

Epidural hematoma (EDH)

Is an EMERGENSY the artery affected is the middle Meningeal! Arterial blood collects between skull & dura. Client may be alert after initial unconsciousness but then becomes increasingly lethargic before lapsing into coma. S/S; headache, ipsilateral (same side as injury) pupil changes & contralateral (opposite side of injury) hemiparesis (weakness or paralysis) * stems from arterial bleeding, from middle meningeal artery & blood accumulate above the dura characterized by rapidly progressive neurologic deterioration.

Parkinson's disease care (Nursing Management)

Manage drug therapy; Levodopa is associated with periods of "breakthrough" or "end-of-dose wearing off" symptoms are exacerbated when a consistent drug level is not maintained. *Nurse must administer the drugs closely to the schedule the client previously established at home. Over time, clients may decreasingly respond to their standard drug therapy and have more frequent "off episodes" of hypomobility in which they may be unable to rise from a chair, speak, or walk. The drugs apomorphine (Apokyn & Stalevo) help in relieving this phenomenon. Drugs administered for parkinsonism can cause a wide variety of adverse effects such as involuntary movements, which require dose adjustments. *The nurse works with physical & occupational therapists to increase the client's level of activity, optimize his or her gait, improve balance, coordination & use adaptive equipment to perform ADLs.

Alzheimer's disease (S/S)

Memory loss (short-term) Eventually, long-term memory becomes impaired *Disturbances in behavior/violent are passible *personality changes *Depression *As the disease advances, the ability of clients to care for themselves deteriorates. Clients may wander & become lost. *Problems with speaking (aphasia) *Reading (alexia) *Writing (agraphia) *Calculating (acalculia) *Agnosia; Inability to recognize objects & sounds (visual, tactile & auditory) Ataxia; difficulty walking & tremors occur. Apraxia; In the final stage of the disease, an inability to accomplish activities of daily living (ADLs), grooming, toileting & eating, despite intact motor function, makes the client totally dependent on others.

myelin (Multiple Sclerosis)

Myelin acts as an insulator, enabling nerve impulses to pass along a nerve fiber. Loss of myelin & subsequent degeneration & atrophy of nerve axons interrupt transmission of impulses along these fibers clients experience worsening symptoms. *As the disease progresses, many complications such as pressure ulcers, cachexia, deformities & contractures develop. Pneumonia, brought about by limited activity, shallow breathing, and general debility, is often the immediate cause of death.

Seizure precautions

Neuro assessment • Preictal (occur before), Aura, postictal (after) • Side rails up and padded • Actions during a seizure • Patient side-lying (post seizure) • Clothing unrestricted • Do not restrain • Do not place any objects in patient's mouth • Privacy *Diagnostic test for Seizures • Urine screening for drugs • Chemistries: • Electrolytes • CBC • ETOH • Blood Sugar• Kidney/Liver studies • CT scan • MRI • Skull X-rays • EEG • Cerebral Angiography

Multiple Sclerosis treatment

No cure, primary aim, keep client functional as long as possible. Nerve regeneration exists in four areas: (1) stimulating nearby oligodendrocytes (cells projections that continue as myelin sheaths) to move to the diseased neurons & replace damaged myelin, (2) identifying & reversing the inhibitors of remyelination, (3) producing growth factors that stimulate natural myelin repair, (4) recruiting replacement cells such as cord blood and fetal stem cells to become myelin-producing cells *Precipitating Factors (MS)(1) Smoking 2. Infection 3. Physical injury (trauma) 4. Emotional stress 5. Pregnancy 6. Poor health

Alzheimer's (medical care)

No cure, treatment is mainly supportive, Six drugs approved by the FDA for treatment of dementia & Alzheimer's (1) cholinesterase inhibitors as donepezil (Aricept), rivastigmine (Exelon) & galantamine hydrobromide (Razadyne), memantine (Namenda); a combination of memantine & donepezil (Namaric). With the exception of memantine, these drugs increase acetylcholine by inhibiting acetylcholinesterase, enzyme that degrades it. When administered in the early to middle stages of AD, some clients improve, some stay the same, some progress more slowly & some fail to respond. All clients eventually get worse over time. Memantine (Namenda) has a different mechanism of action than the acetylcholinesterase inhibitors. Memantine is a neuroprotective drug classified as an N-methyl-D-aspartate (NMDA) antagonist. By blocking NMDA receptors, the drug protects neurons from excessive stimulation by glutamate, an excitatory neurotransmitter responsible for neuronal death. Clients in advanced stages of AD experienced less deterioration when taking memantine than others who were given a placebo.

stroke findings (assessment)

Numbness or weakness of one side of the face, arm, or leg • Mental confusion • Difficulty speaking or understanding • Impaired walking or coordination • Severe headache • Hemiplegia (paralysis on one side of the body) • Right-sided: expressive aphasia, receptive aphasia, slow and cautious behavior • Left-sided: spatial-perceptual defects, poor judgment, midjudge distances• Hemianopia the ability to see only half of the normal visual field Confusion Emotional lability Hemianopia on the affected side is another potential consequence. Hemianopia is the ability to see only half of the normal visual field. When looking straight ahead, the client cannot see to the right (in left-sided stroke) or left (in right-sided stroke) with either eye. This condition is caused by damage to the visual area of the cerebral cortex or its connections to the brain stem (optic radiations). Neurologic deficits that result from a CVA may subside completely, partially, or not at all

Nursing Management

Obtain a complete history of symptoms, medical, drug, allergy histories • Weights, capillary blood sugar, vital signs, smoking history • Neurologic examination *Carotid artery surgery: postoperative • Frequent neurologic checks to detect paralysis, confusion, facial asymmetry, aphasia • Monitor for swelling in neck, difficulty with airway, decrease swallowing or hoarseness • Monitor heart rhythm

nurse management (Cerebral hematoma)

Obtains injury history & performs a neurologic examination, pay attention to V/S; LOC; presence or absence of movement in the arms/legs *Pupil size, equality & reaction to light. If trauma caused the head injury, examines the head for bleeding, abrasions & lacerations. *Evaluates respiratory status, pay attention to the client's ability to maintain adequate oxygenation. Reports neurologic changes immediately

Assessment finding (Encephalitis)

S/S; sudden fever, severe headache, stiff neck, vomiting, & drowsiness, tremors, seizures • Spastic or flaccid paralysis, irritability • Muscle weakness, lethargy, delirium, coma • Incontinence • Visual disturbances photophobia, involuntary eye movements & double or blurred vision occur. • Look for insect bites *During physical assessment, check insect bites. exposure to mosquitoes, other vectors, or a neurotoxic substance. As the infection worsens, the client may develop the above S/S *A lumbar puncture is performed; CSF pressure is elevated, but the fluid is clear. *CT, MRI

Oder adults ( Identify rehabilitation as key therapy affecting post CVA management)

Older adult is more susceptible to complications of prolonged bed rest & inactivity as hypostatic pneumonia, pressure ulcers & contractures that may be involved in the rehabilitation period after a CVA. *HCP; should ovoid stereotypes that suggest older person may lack motivation or ability to participate in rehabilitations efforts, or that the outcomes will NOT be positive! HCP; may need to teach family & friends to encourage the person with a CVA during rehabilitation to provide motivation & support. Rehabilitation of the older client with a CVA is subject to more complications than rehabilitation of a younger adult. The nurse must work closely with the family & social service agencies to help the family assume the care of the client to the extent possible or to facilitate a transfer to a rehabilitation center or long-term care facility.

older adults (Parkinson's)

Older adults with Parkinson's disease are more susceptible to the complications of prolonged bed rest & immobility. Observed client closely for problems as hypostatic pneumonia, pressure ulcers, contractures & deformities. Physical/occupational therapy goals is to maintain comfort or function rather than achieving rehabilitation. Techniques can be taught to compensate for embarrassing or disabling symptoms such as shuffling, freezing gait, nuchal rigidity & lack of control of swallowing to enable the older person to maintain self-esteem and social interactions.

Types of seizures (are divide into two general categories)

PARCIAL or Focal; one hemisphere involve and Generalized seizures-Both hemispheres, the entire brain *Absence seizure: stares blankly, eyelids flutter, lack of prominent movements *Myoclonic seizure: sudden, excessive jerking *Tonic-colonic seizure: muscle alternate between contraction & relaxation; jerkin

Medical (Management/treatments) (Parkinson's Disease)

Prolonging independence. Drugs as selegiline (Eldepryl), Dopaminergic; levodopa (Larodopa) or levodopa-carbidopa (Sinemet); amantadine (Symmetrel); dopamine agonists such as bromocriptine (Parlodel); apomorphine (Apokyn), the newest approved drug; and anticholinergics such as benztropine (Cogentin) are prescribed. Their sequence of use is based on the stage of the disorder and the decreasing effectiveness of the medication initially prescribed. Rehabilitation measures such as physical therapy, occupational therapy, client and family education, and counseling are used concurrently with drug therapy.

Treatment for meningitis (Medical Management)

Reduce ICP in acute stage of infection precautions against diseases, hand hygiene are important in controlling the spread of infection. The local public health department is notified of all cases. *IV fluids & antimicrobial therapy started immediately when bacterial is suspected. Anticonvulsant; for seizures Immunization: meningococcal meningitis for colleges & universities now recommend * Appropriate antibiotic; penicillin *Cephalosporin, rifampin (rifadin) *Vancomycin or chloromycetin

Tonic colonic Seizures

Referred as Grand Mal Seizures are characterized by sequences of events Begins with preictal (or prodromal) phase- Time immediately before the seizure & consists of vague changes, feeling as depression, anxiety, nervousness It last minutes or hrs. Follow by an Aura - sensation that occurs right before seizure; hallucinatory odor or sound, weakness/numbness. Aural followed by; Epileptic cry; spasm of the respiratory muscles * Postictal phase - After the seizure. Deep sleep, headache, fatigue, confusion, nausea & muscle soreness

Seizures (Epilepsy)

Seizures, convulsions, are paroxysmal (sudden attack) episodes in which there are sudden & violent involuntary contractions of a group of skeletal muscles & disturbances in consciousness, behavior, sensations, & autonomic function *Abnormal sudden excessive discharge of electrical activities within the brain *Epilepsy; recurring seizures caused by a chronic underlying condition. • Status Epilepticus (SE) is a state of continuous seizure activity or a condition in which seizures recur in rapid succession without return to consciousness between seizures CAUSES! vascular anomalies tumors, hematomas in or surrounding the brain *Trauma *Acute cerebral edema *Infections: encephalitis Vascular lesions: Emboli, CVA

pharmacologic considerations (multiple sclerosis)

Serious issues with the following newer MS agents: Teriflunomide (Aubagio) can cause birth defects. Women should be tested for pregnancy before starting this drug and use effective birth control while taking the drug. Men whose partners plan to become pregnant should not use this drug either. Fingolimod (Gilenva) may cause progressive multifocal leukoencephalopathy (a rare but serious brain infection). *All the disease-modifying drugs can decrease immune cells and infection protection. Therefore, be aware of increased risk for acquired infections, especially if the client is catheterized

Left side hemiplegia (CVA) (Stroke on right side of Brain affect the left side)

Spatial-perceptual defects Tendency to distractibility Impulsive behavior; unaware of deficits *Poor judgment Defects in left visual fields *Misjudging distances Difficulty distinguishing upside down and right side up *Impairment of short-term memory Neglect of left side of body; objects & people on left side *Hemianopia; ability to see only half of the visual field:)

lumber puncture

Strict aseptic technique is required during procedure *lumbar puncture is performed to obtain samples of cerebrospinal fluid(CSF) from the subarachnoid space for laboratory examination/measure CSF pressure. Bacteriologic tests on specimens of CSF reveal the presence of pathogenic microorganisms. *Recline for period of time after the test & increase oral fluid intake

Delirium

Sudden, transient state of confusion (depend on the cause). They may have difficulty processing information & disoriented as date, time & location. *Judgment impaired, or they may be unable to perform intellectually at the same capacity as in the past. *Some clients may be suspicious, frightened or behave inappropriately. Causes; high fever, head trauma, brain tumor, drug intoxication or withdrawal, metabolic disorders as liver or renal failure, or inflammatory disorders of the CNS, as meningitis or encephalitis. *Treatment; underlying medical condition usually restores mental functions. *Differences from Dementia are the following (1) ONSET; sudden (2)presentation; Blunted/inattentive (3)course; unstable, fluctuations in functions & extended brief (4)Duration; Temporary (5)Treatment; Specific (6)outcome; CURABLE

Assessment finding (TIA)

Temporary lightheadedness; confusion; speech disturbances; loss of vision; diplopia; variable changes in consciousness; & numbness, weakness, impaired muscle coordination, or paralysis on one side Diagnostic Findings• Examination: auscultation of the carotid artery may reveal a bruit (abnormal sound caused by blood flowing over the rough surface of one or both carotid arteries) • Other: ultrasound examination, carotid arteriogram, CT scan, MRI

Intracranial surgery (consist of 3 procedures)

The bone flap is removed to provide a visual field for surgery. After surgery, the bone flap is replaced. If an inoperable tumor, the bone flap is not replaced, allowing the tumor to expand & reducing ICP rate. Complications associated with intracranial surgery *cerebral edema *infection *neurogenic shock *fluid/electrolyte imbalances *venous thrombosis (especially in the arms and legs), *increased ICP *seizures *leakage of cerebrospinal fluid (CSF) *stress ulcers and hemorrhage

Pathophysiology (Etiology/Meningitis)

The most highly contagious/potentially lethal form of meningitis usually affects school-aged children, young adults & immunosuppressed people/older adults The infecting microorganisms circulate from blood & lymph to cerebral capillaries or by direct extension from infected areas such as middle ear & paranasal sinuses. When the pathogens arrive in the cerebral circulation, they travel to the subarachnoid space of the meninges where the inflammatory process begins. Inappropriate secretion of antidiuretic hormone lead to cerebral edema, ^ fluid volume & cause ^ ICP. Cerebral vasculitis, inflammation of blood vessels in the brain, may be present, & cerebral blood flow may be decreased. The client may develop seizures, a brain abscess, neurologic changes, irreversible coma, & death from brain herniation. Neurologic sequelae in survivors include damage to the cranial nerves that facilitate vision and hearing

CVA/ assessment

Time symptoms began Medical, drug & allergy history from the family (or client if he or she can report) Vital signs/LOC Size & response of pupils to light Any musculoskeletal weakness or paralysis Capacity to speak or understand spoken language Changes in visual field Ability to swallow Any alteration in bladder or bowel control Integrity of the skin; evidence of soft tissue injury as a consequence of falling *Care/considerations *Impaired Swallowing related to hemiplegia *Use a thickening agent; keep a suction machine. * Risk for Imbalanced Nutrition *Request small, frequent nourishment. *Risk for Impaired Skin Integrity related to immobility *Use pressure-relieving devices or therapeutic bed. *Impaired Verbal Communication related to aphasia *Instruct client to speak slowly. *Risk for Ineffective Coping *Acknowledge personal strengths

Transent Ischemic Attack (TIA)

Transient Ischemic Attack (TIA) •Sudden, brief episode of neurologic impairment caused by a temporary interruption in cerebral blood flow. • Symptoms last from 1 hour to 1 day • Causes: atherosclerosis, arteriosclerosis, cardiac disease, diabetes *TIA; is a warning that a cerebrovascular accident can occur in the near future; one-third of people who experience TIA subsequently develop a stroke

Medical (Encephalitis)

Treatment depend on the cause; supportive *antivirals; herpes-Acyclovir (Zovirax) antifungals antipyretics anti-inflammatory drugs analgesics & *anticonvulsants for Seizure Nursing; monitors V/S & LOC frequently compares findings with previous assessments. If urinary retention or urinary incontinence develops, consults HCP to discuss an indwelling urethral catheter is appropriate *The nurse measures fluid intake/output to detect signs of fluid volume deficit & electrolyte imbalances Assesses bowel elimination to determine if the client needs an enema or a stool softener. lists measures for reducing potential bites from mosquitoes as culex species of mosquitoes that transmit West Nile virus and St. Louis encephalitis, anopheles mosquitoes that causes malaria, and the Aedes a gypti mosquitoes that transmit the Zika virus.

Nutrition (Parkinson's Disease)

Unintentional weight loss is a common risk for morbidity/mortality. Weight loss may be due ^ energy expenditure related to tremor; due to impaired intake related to diminished sense of smell, dysphagia, or depression; or from medication side effects such as dry mouth, nausea, anorexia, fatigue, or anxiety *Strategies to prevent or treat unintentional weight loss may include small, frequent meals. Dysphagia-cut food up, easy chew & provide semisolid foods to facilitate swallowing, *increasing calorie density of foods served by added sauces, gravies *Constipation; Foods high in fiber, as crushed bran added to hot cereal & fiber-fortified supplements & consumed adequate fluids. Prunes and prune juice stimulate peristalsis. Clients taking levodopa should avoid high intake of protein (meat, fish, poultry, and dairy foods) because protein decreases its effectiveness. However, a high-protein diet may be needed for clients who experience unintentional weight loss.

Subdural Hematoma (SDH)

Venous blood collects between the dura & subarachnoid layers. *Deterioration in LOC is progressive. * ipsilateral pupil changes, Decreased extraocular muscle movement *Contralateral hemiparesis, with periodic episodes of memory lapse, confusion, drowsiness, personality changes. *Results from venous bleeding, with blood gradually accumulating in the space below the dura. Subdural H; are classified as acute, subacute & chronic Acute; Symptoms progressively worsen within the first 24hrs of the head injury. *Client with subacute & chronic subdural H; become symptomatic after 24hrs & up to 1 week later.

Meningitis

inflammation of the meninges caused by various infectious microorganisms as; bacteria meningococci Streptococci... viruses: Viruses herpes simplex, mumps, enteroviruses *virus meningitis is more common in children, common intestinal viruses, Fungi, or parasites. inflammation often extends to the cerebral cortex. Depend on the organism, the client's condition may be mild or rapidly become critical. Most adults with bacterial meningitis, recover without permanent neurologic damage or dysfunction, but if complications occur they are usually serious.

Encephalitis (Pathophysiology)

inflammatory process affecting the CNS. It is characterized by swelling of the brain & pathologic changes in both the white/gray matter & surrounding meninges. *Causes: Viral, bacterial, fungi, or parasite but the most common include vector-borne viral infections, complications from viral infection as rubeola (measles), or neurotoxic effects associated with childhood vaccination. Viruses that cause encephalitis include the St. Louis, western equine, eastern equine, and West Nile viruses. Ticks or mosquitoes can transmit some of these viruses. Infected birds bitten by the common culex mosquito can transmit West Nile and St. Louis viruses. The virus remains in the mosquito's salivary glands, & the mosquito can inject the virus into humans & animals during blood feeding. Client experience no, mild flulike symptoms, others become severely ill & die from subsequent encephalitis *Poisoning by drugs/chemicals, as lead, arsenic & carbon monoxide, may closely resemble encephalitis clinically. When encephalitis occurs, there is severe, diffuse inflammation of the brain. Nerve cell destruction can be extensive. Cerebral edema, neurologic deficits such as paralysis & speech changes, increased ICP, respiratory failure, seizure disorders, and shock can occur

Older adult (meningitis)

may not exhibit the typical S/S of meningitis; rather, they may display a change in mental status, slight to no fever, and no nuchal rigidity or headache. Mortality rates are high in older adults with this disease partly because of these atypical signs and symptoms. Contributing factors to death from meningitis are chronic illness and delays in diagnosis.

Neuromuscular disorders

involves the nervous system & indirectly affects the muscles. Ex; Multiple sclerosis Myasthenia gravis & amyotrophic lateral sclerosis (ALS)—all of which are chronic and progressively debilitating *Extrapyramidal disorders Origin in the motor cortex & surrounding areas of the cerebellum & basal ganglia. EX; Parkinson's disease & Huntington's disease. primary characteristics abnormal movement; *PD's; begins after 50 yrs of age. It primarily affects the basal ganglia & connections in the substantia nigra & corpus striatum. *Extrapyramidal Disorder (assessment) Determine the following: Year of current diagnosis Concurrent medical disorders Weight and vital signs Any unilateral or bilateral hand tremor Gait and balance Use of assistive ambulatory devices Ability to swallow Quality of speech Bowel and urinary elimination patterns Mental and emotional status Drug therapy, time and frequency of medication administration

Preoperative Care (cerebral Hematoma)

prepares for surgery *uses electric hair clippers to remove hair where burr holes will be drilled or an incision will be made (deferred/put off until he is in operate room). *Takes V/S maintain record of continuing neurologic assessment findings...Administers prescribed drugs, as anticonvulsant phenytoin (Dilantin) to reduce the risk of seizures before & after surgery, an osmotic diuretic & corticosteroids. *Preoperative sedation usually omitted. *Before surgery, Restricts fluids to avoid intraoperative complications, reduce cerebral edema & prevent postoperative vomiting. *If indicated, inserts an indwelling urethral catheter & IV line. *Applies antiembolism stockings to prevent thrombophlebitis & deep vein thrombosis, which may develop from prolonged inactivity during neurosurgery.

Teach client exposure to mosquitoes

reports concerning incidence of birds infected with West Nile virus or St. Louis virus in your community. Avoid being outdoors during peak mosquito biting times, such as early evening. Wear clothing that covers as much skin as possible when outdoors. Apply insect repellant containing permethrin or DEET to clothing and exposed skin. Repair or replace windows and door screens. Place netting around strollers and infant carriers. Empty outdoor items frequently that may hold standing water, such as pet dishes, birdbaths, flowerpots, and pool covers. Transport discarded tires to a location for waste management. Clear gutters of debris that may obstruct the drainage of rainwater

*In the absence of dopamine, another area of the brain, known as the globus pallidus, which responds to acetylcholine, becomes overactive. The imbalance between dopamine & acetylcholine results in a movement disorder that characterizes Parkinson's disease. *PD'S Begins after 50 yrs of age. It primarily affects the basal ganglia & connections in the substantia nigra & corpus striatum. The term parkinsonism describe cluster of symptoms develops from several etiologies In most cases no cause is found for dopamine depletion

self-administration of an illegal synthetic form of heroin known as MPTP Parkinson's Disease( extra) *Phenothiazines, a category of antipsychotic drugs & dopamine receptor-blocking antipsychotic drugs used to treat schizophrenia, also produce what is referred to as pseudo parkinsonism because the symptoms are reversible when the drug is discontinued. Manifestations of the disorder progress so slowly that years may elapse between the first symptom& diagnosis. The symptoms initially are unilateral, but eventually, whether quickly or slowly, become bilateral.

Parkinson's Disease (Assessment Findings S/S)

stiffness, referred to as rigidity, & a pill-rolling tremor (a circular movement of the fingers & wrist as if manipulating a small object or pill within the palm) of hands. The hand tremor is obvious at rest & typically decreases when movement is voluntary as picking up an object. *Bradykinesia; slow in performing spontaneous movements * Masklike expression *stooped posture, hypophonia (low volume of speech) *Difficulty swallowing saliva & food. Weight loss occurs *Constipation Orthostatic hypotension *Shuffling gait is apparent, client has difficulty turning or redirecting forward motion *Arms are rigid while walking *In late stages, affects jaw, tongue, & larynx; speech is slurred *Chewing & swallowing become difficult. Rigidity can lead to contractures (tight muscles) Constipation *Orthostatic hypotension *Salivation ^ accompanied by drooling. high risk for aspiration. some clients, eyes roll upward or downward & stay there involuntarily (oculogyric crises) for several hours or even a few days.