Neuro Part 2 Chapter 67, 69-70

Dysarthria

Defects of articulation d/t neurologic causes

Ischemic stroke manifestations

Depend on location & size of affected area Numbness or weakness or the face, arm, or leg, especially on one side Confusion or change in mental status Trouble speaking/understanding speech Difficulty walking, dizziness, loss of balance or coordination Severe, sudden HA Perceptual disturbances

What are the psychiatric changes seen in Parkinson's Disease?

Depression Anxiety Dementia Delirium Hallucination

Dysphagia

Difficulty swallowing

which finding would the nurse expect to observe in an initial assessment of a client with myasthenia gravis?

ptosis and diplopia (droopy eyelid, double vision)

Receptive aphasia

Inability to understand what someone else is saying

Fungal Meningitis CSF

Opening Pressure: >200 WBC count >20 Glucose: <40

Extramedullary/extradural

Outside dural membrane

Deep brain stimulation

Pacemaker for brain patient with Levodopa success & dyskinesias impaired had disease for at least 5 years disabled by tremor May increase dopamine release May block anticholinergic release * Improves tremor and rigidity

Hemiplegia

Paralysis of one side of the body, or part of it, due to an injury in the motor area of the brain

Vector-born manifestations

rash flaccid paralysis Parkinson-like movement

Types of meningitis

septic aseptic

the nurse is aware that, when assessing a patient for symptoms of a brain tumor, the symptom most frequently found is:

simple to generalized seizures

a nurse is assessing a client with Parkinson's disease. Which of the following would the nurse expect to find?

slowing of activity

Brain tumor medical management

specific treatment depends on * type/location/accessibility Surgery Chemotherapy Medications

Parkinson's Disease surgical procedures

stereotatic Thalamotomy/pallidotomy * Destroy brain tissue, rarely used today Deep brain stimulation

What should happen if a patient on tPA starts bleeding

stop tPA get CT scan give antidote * Tranexamic Acid (TXA)

What should happen if a patient on tPA ℅ HA

stop tPA, contact MD for CT

which of the following provides the best outcome for most tumor types?

surgery

a client has been diagnosed with trigeminal neuralgia. The nurse should recognize what implication of this diagnosis?

the client needs to be assessed for MS

when should the nurse plan the rehabilitation of a patient who is having an ischemic stroke?

the day the patient has the stroke (only delay if they are on TPA)

Trigeminal neuralgia

tic douloureaux

Hemianopsia

Blindness of half of the field of vision in one or both eyes

Types of MS

Relapse-remitting Primary progressive **WORST Secondary progressive Progressive-relapsing

What are the cardinal manifestations of parkinsons disease?

tremor rigidity bradykinesia, akinesia postural instability dysphagia

How do tumors look on a CT

tumors are more solid

How does an abscess look on a CT

typically have a more/better defined edge

Vasospasm risk

up to 21 days after SAH

what should the nurse tell the client to explain the long length of stay after a SAH?

vasospasms are a risk up to 21 days after SAH

Encephalitis causes

viral infections (herpes simplex) * Most common vector-born viral infections (west nile, St. Louis) Fungal infections * not often seen in healthy patients

which of the following would the nurse identify as the primary initial symptoms of an ischemic stroke?

weakness on one side of the body and difficulty with speech

brudzinski sign

when patient lying flat, neck is bent forward (chin toward chest), this causes the hips to flex

Kernig sign

when patient lying with thigh flexed on the abdomen, the leg cannot be completely extended

Malignant

Invades/spreads

AMYOTROPHIC LATERAL SCLEROSIS (ALS)

"Lou Gehrig's" Loss of motor neurons in anterior horn Loss of motor nuclei in lower brain stem

a nurse is teaching a client who was recently diagnosed with myasthenia gravis. Which statement should the nurse include?

"this disease doesn't cause sensory impairment" (motor impairment)

tPA

18 or older Clinical dx ischemic stroke <3 hrs since onset of symptoms (can wait up to 4.5 hrs) Systolic BP 185 or less, diastolic BP 110 or less No seizure at onset of stroke No heparin in the past 48 hrs Plt ct 100000 or more Glucose > 50 no prior intracranial hemorrhage, neoplasm, AVM or aneurysm No major surgical procedures or serious trauma w/in 14 days No stroke, serious head injury or intracranial surgery w/in 3 months No GI/GU bleeding w/in 21 days No pregnancy

CJD & vCJD Manifestations

Affective, sensory, motor and cognitive impairments Takes years for clinical signs to show up Once signs have appeared lifespan is about 22 months for vCJD and 1 year for CJD

Secondary prevention

After CVA/TIA Trying to keep pt from having another stroke Carotid endarterectomy for carotid stenosis Anticoagulant Tx for A-Fib (Coumadin-Warfarin) Antiplatelet therapy Statins Antihypertensive medications

Nonmodifiable risk factors of stroke

Age (older than 55) Gender (Males > Females) Race (more in African Americans)

Degenerative disc disease changes occur with

Aging * Twisting & moving wears disc down over time Result of trauma

which of the following, if left untreated, can lead to an ischemic stroke?

A-fib

Arterial venous malformations

AVM artery and vein are connected Causes increased arterial pressure

Encephalitis

Acute, inflammatory process of the brain tissue

Spinal cord tumors classified according to

Anatomic relation to spinal cord

Ischemic Stroke

Approximately 87% of all strokes Disruption of the blood supply caused by an obstruction, thrombus or embolism, causes infarction of brain tissue

Penumbra region

Area of low cerebral blood flow associated with a stroke Tissue may be salvaged with quick intervention

Primary tumor

Arise from brain tissue

if warfarin is contraindicated as a treatment for stroke, which medication is the best option?

Aspirin

Trigeminal neuralgia management

Antiseizure meds Carbamazepine (Tegretol) Gabapentin (Neurontin) Phenytoin Antispasmodic Baciofen (Lioresal) Surgery Microvascular decompression of CN V Radiofrequency thermal coagulation

Hemorrhagic Stroke

Approximately 13% of all strokes Caused by bleeding into brain tissue, the ventricles, or subarachnoid space Brain metabolism disrupted by exposure to blood ICP increases d/t blood in subarachnoid space Compression and secondary ischemia results from reduced perfusion and vasoconstriction

Stroke post-acute phase medical management

Assess mental status Sensation/perception swallowing ability nutritional & hydration status skin integrity activity tolerance bowel & bladder function

Myasthenia Gravis

Autoimmune disorder affecting the myoneural junction and is characterized by varying degrees of voluntary muscle weakness Antibodies attack receptor site * Little or no acetylcholine available * Muscles can't contract Motor disorder * Autoimmune affecting myoneural junction

Guillain-Barre syndrome

Autoimmune disorder with acute attack of peripheral nerve myelin Very fast! Peak within 2-4 weeks Rapid demyelination may produce respiratory failure and ANS dysfunction w/ CV instability Most often follows viral infection

a client with Guillain

Barre states, "it's getting harder to take a deep breath" what should the nurse do?-call the physician and prepare for intubation

a client is hospitalized with Guillain

Barre. Which nursing assessment finding is most significant?-even, unlabored respirations (because you know they're not in danger yet, no interbentions needed)

Spinal cord tumor assessment

Baseline neurologic exam Patient function/moving/walking Adaptation to weakness/paralysis/vision & speech loss/seizures Pain Respiratory systems Bowel & bladder function Sleep Skin integrity Fluid balance Temperature regulation Nutritional history Family coping/processes

Trigeminal neuralgia (tic douloureux)

CN V Extremely painful 2nd & 3rd branches of nerve Vascular compression/pressures probable cause Mainly in women age 50-60 years/people with MS

Acoustic neuroma

CN VIII Slow growing so gets really big before symptoms noticeable Brain compensates Might notice hearing loss/vertigo Eventually brain can't compensate

Stroke diagnosis

CT Scan Cerebral angiography Lumbar puncture If CT is negative & ICP not elevated Confirms SAH

Cerebral Vascular Accident

CVA Stroke Brain Attack

Stroke management

Care primarily supportive Bed rest w/ sedation Oxygen Tx of vasospasm, increased ICP, HTN, potential seizures Prevention of further bleeding

Huntington's disease

Chronic progressive hereditary disease that results in Choreiform movement * Rapid, jerky movements/tics Dementia

Brain Abscess

Collection of infectious material within brain tissue Bacteria the most common causative organism Prevented by treating otitis media, rhinosinusitis CT-guided aspiration used to ID causative organisms

Brain abscess medical management

Control ICP Drain abscess Admin ABT therapy Corticosteroids possibly for cerebral edema

Parkinson's Disease treatment

Directed at controlling symptoms Maintaining functional independence:Parkinson's Disease pharmacological treatment-Lovadopa * Most effective/mainstay of treatment * Converted to dopamine in basal ganglia - gives relief of symptoms * Side effects become more severe over time - Dyskinesia - On-off syndrome (immobility followed by return to effectiveness) - Nausea/vomiting/appetite loss - Decreased BP - Dystonia/dyskinesia/confusion Cogentin * Counteract action of acetylcholine (anticholinergic)

Myasthenia Gravis Medical Management

Directed at improving function/reducing & removing circulating antibodies Antichoinesterase medications * Pyridostigmine bromide * Use 1st due to less side effects * Gets rid of cholinesterase * More acetylcholine is available due to open receptor sites IV immune globulin (IVIG) * Corticosteroids - Prednisone * Azathioprine (Imuran) * Immune suppressant/Cytotoxic/Last resort Plasmapheresis * Removes antibodies * Thymectomy

Medical Management of MS

Disease-modifying therapies IV methylprednisolone shortens the relapse *no long-term effect Symptom management of Muscle spasms Fatigue Ataxia Bowel & bladder control Glatiramer acetate reduces rate of relapse Most medications ineffective for progressive course!

Glioblastoma

Divide/grow faster Grades 3 & 4

Benign tumor

Doesn't invade/spread

Spinal cord tumor manifestations

Early manifestation * Pain Weakness Loss of motor function Loss of reflexes Loss of sensation Tumor at Cervical area * Respiratory changes

Vasospasm

Early signs of stroke. If treated quickly stroke can be prevented

Myasthenia crisis management

Educate patient in signs & symptoms of MG and CC Make sure patient isn't over-medicated to cause CC Ensure adequate ventilation * Intubation & mechanical ventilation may be needed Assessment & supportive measures * Ensure airway & respiratory support * ABGs, serum electrolytes, I & O, daily weight * NG tube if patient can't swallow * NO SEDATIVES/TRANQUILIZERS - Don't knock out what little function exists

Trigeminal neuralgia interventions

Education * Pain prevention * Treatment regimen * Side effects of seizure medicine * Avoid triggers Strategies to improve nutrition * Soft food * Chew on unaffected side * Avoid hot/cold food Provide interventions to address * Anxiety * Depression * Insomnia

the nurse is caring for a client with aphasia. Which strategy will the nurse use to facilitate communication?

Establishing eye contact

Stroke acute phase medical management

Evaluate by CT (looking for blood) Lumbar puncture if SAH believed to be happening Elevate HOB - unless contraindicated Neuro assessment & vital signs LOC Monitor for pupil changes I & O O2 saturation

S/S seen with exacerbation of MS

Fatigue Weakness Numbness Coordination difficulty Loss of balance Pain Visual disturbances

Meningitis nursing management

Freq or continual assessment, including VS & LOC Pain & fever management Protect from injury r/t seizure activity or LOC Monitor daily wt, serum electrolytes, urine volume, specific gravity, osmolality Prevent immobility associated complications Supportive care

Stereotatic procedures

GAMMA knife * very targeted, really high radiation Non-invasive A week or more before results seen laser could cause necrosis

Meningitis manifestations

HA fever LOC changes behavioral changes nuchal rigidity (stiff neck) Positive kernig sign positive brudzinski sign photophobia

which finding would nurse expect on initial assessment of a client with possible brain abscess?

HA that is worse in the morning

Brain abscess manifestations

HA, usually worse in the morning Fever Vomiting Neuro deficits S/S increased ICP

Modifiable risk factors of stroke

HTN primary DM * Greater risk when combined with HTN Cardiovascular disease Elevated cholesterol Elevated hematocrit Obesity Oral Contraceptive use Smoking Drug & Alcohol abuse

Process of demyelination

Immune system destroys myelin sheath! Inflammation destroys myelin sheath Conduction interrupted

Multiple Sclerosis (MS)

Immune-mediated , progressive demyelinating disease of the CNS Clinical manifestations vary and have different patterns Frequent relapse & remission Can cause social isolation due to debilitating pain & fatigue! Patients degenerate

Guillain-Barre syndrome planning

Improved * Respiratory function, mobility, nutrition, communication, coping Decreased fear & anxiety Absence of complications As patient gets better these conditions will improve

Astrocytoma

In astrocytes of glial cells Slow growing Grades 1 & 2

Meningiomas

In meninges

Expressive aphasia

Inability to express oneself often associated with damage to the left frontal lobe area

Aphasia

Inability to express oneself or to understand language

Apraxia

Inability to perform previously learned purposeful motor acts on a voluntary basis

Creutzfeldt

Jakob Disease (CJD) & variant Creutzfeldt-Jakob Disease (vCJD)-AKA Mad-Cow disease Rare, degenerative infectious, transmissible spongiform encephalopathies (TSEs) Caused by prions (smaller than viruses & resistant to sterilization) Not spread via casual contact * Carried in CSF and eye fluid

which is a component of the nursing management of the client with variant Creutzfeldt

Jakob disease (CJD)?-providing palliative care (it's a 100% fatal disease)

Vasospasm Treatment

Keep fluid volumes up Calcium Channel blockers * Nimodipine Keep BP up

What to monitor with tPA

LOC ℅ HA CT or MRI 24 hrs after tPA starts.

Ischemic stroke causes

Large artery thrombosis Small penetrating artery thrombosis Cardiogenic embolic Cryptogenic, no known cause Other

Brain tumor manifestations

Localized or generalized symptoms Symptoms of increased ICP * Altered LOC due to brain compensating Headache Vomiting * Vagal center in medulla Vision disturbances Seizures * 60% will have seizure

Brain tumor classification based on

Location Histologic characteristics * Mitosis of cell

Agnosia

Loss of ability to recognize objects through a particular sensory system

Brain abscess diagnosis

MRI or CT

Bell Palsy Management

Medical * Corticosteroid therapy - Reduce inflammation/diminish severity Nursing * Provide education & reassurance that stroke hasn't happened * Protect eye from injury!! - Raised eye shield at night - Ointment/sunglasses * Facial exercises/massage - To maintain muscle tone

Guillain-Barre syndrome medical management

Medical emergency!! Requires ICU management w/ continuous monitoring & respiratory support - intubation Plasmapheresis & IVIG To reduce circulating antibodies Recovery rates vary, most completely recover Chronic disease Will always have so avoid triggers

Degenerative disc disease medical management

Medications * pain medicine * dexamethasone * injected corticosteroid * muscle relaxant Surgery may be required

Infectious Neurologic Disorders

Meningitis Brain abscess Encephalitis Crutzfeldt-Jakob disease or variant Crutzfeldt-Jakob disease

Duchenne muscular dystrophy

Most common Inherited as sex-linked trait Passed from fathers because x chromosome linked

Glioma

Most common in cerebral tissue Glial cells surround neurons and give support Can infiltrate any portion of brain Astrocytoma Glioblastoma Meningioma Acoustic neuroma Pituitary adenoma

Diagnostic tests for brain tumor

Neurologic exam * Check deficits CT * Check for tumor MRI * Differentiate between tumor & abscess PET * Detect cancer cells EEG * Seizure activity Cytologic study of cerebrospinal fluid Biopsy

a client has had a SAH (subarachnoid hemorrhage). the nurse anticipates which therapeutic intervention?

Nimodipine PO, CCB(reducing risk of vasospasms)

CJD & vCJD Treatment

No effective treatment, progressive and fatal

Myasthenia Gravis Manifestations

Ocular muscles initially Diplopia Ptosis Facial muscle weakness Impaired swallowing Impaired, nasally voice (dysphonia) Generalized weakness

Guillain-Barre syndrome Assessment

Ongoing assessment with emphasis on Respiratory failure Make sure they can breathe!! Cardiac dysrhythmias DVT Patient & family coping HUGE!

Normal CSF

Opening Pressure: 100-180 WBC count: 0-5 Glucose: 45-80 (0.6x blood glucose level)

Bacterial Meningitis CSF

Opening Pressure: 200-500 WBC count: 100-5000 Glucose <40 (0.4x blood glucose level)

Viral Meningitis CSF

Opening Pressure: 250 or greater WBC count: 50-1000 Glucose: >45

Huntington's disease pathophysiology

Premature death of cells Basal ganglia (movement control) Cortex (thinking/memory/perception/judgement) Cognitive impairment Behavioral problems Progressive/gets worse

Meningitis medical management

Prevention through the meningococcal vaccine * 11-12 years old * booster 16 years old * First year college students * Military members Early admin of high doses of IV antibiotics Must cross the blood brain barrier * PCN-G or cephalosporins * Dexamethasone Tx for shock, dehydration & seizures

ALS Manifestations

Progressive weakness, atrophy Cramps, twitching, lack of coordination Spasticity, DTR brisk and over-active Difficulty speaking, swallowing, breathing Doesn't affect cognition

Aneurysm Precautions

Provide non stimulating environment (prevent increase of ICP), dim lighting, no reading, no TV, no radio Absolute bed rest HOB 30 degrees No extreme flexion of the hips, increases intraabdominal pressure which increases ICP Stool softeners & mild laxatives No acute flexion of head or neck Restrict visitors Keep BP on the lower side

Cholinergic Crisis

Rare Caused by overmedication of cholinesterase inhibitors Severe muscle weakness w/ respiratory & bulbar weakness Patient may develop respiratory compromise failure

Brain tumor surgery

Remove tumor without increasing symptoms Relieve symptoms by decompression Best thing to do is to take out tumor!! Craniotomy Transsphenoidal Stereotatic procedures Radiation

Guillain-Barre syndrome collaborative problems/complications

Respiratory failure ANS dysfunction DVT/PE Urinary retention

Myasthenia crisis

Result of exacerbation or precipitating event Usually respiratory infection Severe generalized muscle weakness w/ respiratory & bulbar weakness Patient may develop respiratory compromise failure

Subarachnoid hemorrhage

SAH Bleeding in the subarachnoid space

Encephalitis manifestations

Seizures HA Fever Confusion Hallucinations

ALZHEIMER'S

Senile dementia Most common cause of dementia Chronic/progressive/degenerative brain disorder Oxidative stress plays roll

Continued pressure on disc may cause changes in

Sensation & motor responses

Hemorrhagic Stroke Manifestations

Severe HA Early & Sudden changes in LOC Vomiting - Projectile Bleeding

Hemorrhagic Stroke Causes

Spontaneous rupture of small vessels primarily related to HTN Subarachnoid hemorrhage caused by a ruptured aneurysm intracerebral hemorrhage r/t amyloid angiopathy Arterial venous malformations (AVMs) Intracranial aneurysms Anticoagulant medications

CJD

Sporadic * no reason to happen * we don't know why Heredity * genetic disorder Acquired * eat it or it gets into your body somehow physical symptoms seen first

What are the autonomic manifestations of Parkinson's Disease?

Sweating Drooling Flushing Orthostatic Hypotension Gastric & Urinary retention

Transient Ischemic Attack

TIA or Mini-stroke Temporary deficit resulting from temporary impairment of blood flow Stroke-like symptoms that resolve on their own "warning of impending stroke" Diagnostic workup required to treat and prevent irreversible deficits

Infarction

Tissue necrosis in an area deprived of blood supply

N. meningitidis

Transmitted by secretions or aerosol contamination infection is likely in dense community groups like college campuses

Hormonal effects with pituitary adenoma due to pituitary being over hypothalamus

Tumor secretes same hormone that pituitary does causing hormone overload * Mood swings * Eating * Blood pressure

Guillain-Barre syndrome interventions

Turn Q2H Assess swallowing/gag reflex to prevent aspiration Compression hose/SCDs Passive ROM at least 2x a day Limbs in functional position Need to have a plan to communicate with patient!!

Spinal cord tumor treatment depends on

Type & location of tumor Surgical removal is most desirable To relieve compression * Dexamethasone combined w/ radiation

Bell Palsy manifestations

Unilateral facial muscle weakness/paralysis * Facial distortion/one side of face drooped * Increased lacrimation * Painful facial sensation Difficulty with speech/eating

MS Intervention

Use collaborative approach * best and only way to treat patients Activity & rest Bowel & bladder control Reinforce/encourage swallowing instructions Strategies to reduce aspiration risk Enhance cognitive function Minimize stress Maintenance of environment temp Assistive devices Modifications for home care management/independence of ADLs Coping support

Guillain-Barre syndrome manifestations

Variable Weakness Paresthesias Pain Diminished/absent reflexes Begin in lower extremities and progress upward Bulbar weakness Cranial nerve symptoms Tachycardia Bradycardia HTN or hypotension

Duchenne muscular dystrophy characteristics

Varying degrees of muscle wasting/weakness Abnormal elevation in muscle enzyme serum levels

Pituitary adenoma

Vision changes due to pituitary being located over optic chiasma & optic nerve

Goals for patients with neuro disorders

Want patient to function at highest possible level Watch for side, effects & depression Monitor for falls/major falls risk!! Ensure realistic goals or patient may become depressed Attaining adequate nutrition Hard to eat due to tremors Dysphagia

Trigeminal neuralgia pain can occur with

Washing face brushing teeth eating draft of air Patients might avoid all these to prevent attack

Hemiparesis

Weakness of one side of the body, or part of it, due to an injury in the motor area of the brain

Intramedullary

Within the cord

which is the primary medical management of vector-born encephalitis?

controlling seizures and increased ICP

Radiation

cornerstone treatment for many brain tumors used often to shrink/de-bulk to relieve ICP symptoms

Encephalitis medical management

acyclovir for HSV infection Amphotericin or other antifungal for fungal infection

Huntington's disease is transmitted as

autosomal dominant trait

Primary prevention

best way before CVA occurs

Intraparenchymal (intracerebral) bleed

bleeding in the brain tissue

Intraventricular bleed

bleeding in the vascular system

the client has had an ischemic stroke. what action should the nurse perform to best prevent joint deformities?

place a pillow in the axilla when there is limited external rotation

Septic

caused by bacteria (streptococcus pneumoniae, neisseria meningitidis)

Aseptic

caused by viral infection secondary to cancer or weak immune system

a client reports a HA in the occipital area and shows ataxia and nystagmus. Which is the most likely cause?

cerebellar abscess

which sign of meningitis is exhibited when the client's neck is flexed and flexion of the knees and hips is produced?

positive Brudzinski sign

Brain tumor pharmacologic therapy

dexamethasone for swelling/HA Mannitol Keppra for seizures

Parkinson's disease is associated with decreased levels of:

dopamine

What neurotransmitter is decreased with Parkinson's Disease?

dopamine

a client is diagnosed with a stroke is having difficulty forming words (motor function, marbled talk) during communication, this is:

dysarthria (marbled talk)

what is the nurse's most appropriate action for a client not receiving treatment for brain metastases?

ensuring that the client receives adequate palliative care or helping them be independent

a nurse is providing care to a client who has had a stroke. which symptoms are consistent with right-sided hemiplegia (Paralysis)?

expressive aphasia, (left hemisphere controls right side of body & includes the language centers)

Bell Palsy

facial paralysis caused by unilateral inflammation of CN VII most patients recover in 3-5 weeks Usually only have it once

which action should the nurse take first to promote client comfort after a lumbar laminectomy?

help the client assume a more comfortable position

the nurse is caring for a client with an inoperable brain tumor. What is the major threat to this client?

increased ICP

Muscular dystrophies

incurable disorders characterized by progressive weakening, wasting of skeletal & voluntary muscles Most are inherited

Meningitis

inflammation of the pia mater, the arachnoid and the CSF filled subarachnoid space Can be caused by bacteria, fungus, or virus N. meningitidis most common

the nurse recognizes the client is demonstrating late signs of ICP when which sign is observed?

irregular respirations (cushings triad, impending herniation)

What do neurologist prefer to give warfarin to prevent CVA?

it is easily reversed with Vitamin K

Brain tumor symptoms depend on

location/size of lesion

What can cause death in Alzheimer's patients?

malnourishment Aspiration PNA

vCJD

may be contracted through ingestion of infected beef Psychological symptoms seen first

a client is diagnosed with ALS the nurse understands that the symptoms of the disease will begin in what way?

numbness and tingling in the lower extremities

S/S CSF leak post

op-Serosanguinous drainage Bulging at site Continuous growing bulge called pseudo-meningiocele * Possible opening in the dura

what change in health status would then nurse attribute to the client's newly diagnosed metastatic brain disease?

personality changes

Transsphenoidal

pituitary tumor watch for CSF leak Diabetes insipidus d/t damaged pituitary that makes too much ADH