Exam #4 (Chp 41-45) Flashcards
(211 cards)
1
Q
What are the 2 major nervous systems?
A
Central Nervous System
Peripheral Nervous System
2
Q
Peripheral Nervous System is divided into two systems, What are they? What do they do?
A
Somatic and Automatic
They work together to control cognition, mobility, and sensory perception.
3
Q
What is the Central Nervous System composed of? And what do they do?
A
The CNS is composed of the:
Brain- directs regulation and function of the nervous system and other boys systems
Spinal cord- initiates reflex activity and transmits impulses to and from the brain.
4
Q
What is the Peripheral Nervous System composed of?
A
12 pairs of cranial nerves
31 pairs of spinal nerves
Autonomic Nervous System (ANS)
5
Q
What does the posterior and anterior parts of the spinal nerves do?
A
Posterior- carries sensory information to the spinal cord (sensory perception- touch, feel, smell, etc)
Anterior- transmits motor impulses (mobility) to the muscles of the body.
6
Q
The ANS is subdivided into which categories?
A
Sympathetic - fight or flight
Parasympathetic - rest and digest
7
Q
What do Neuroglia cells do?
A
Provide protection, structure, and nutrition to neurons
They are part of the blood-drain barrier and help regulate CSF.
8
Q
What are the key components of a neurological assessment:
A
Assess appearance, speech, affect and motor function Medical Hx / Family Hx ADL performance Pt's Memory (especially recent memory) Mental Status (including orientation) Establish baseline data Compare R and L sides, and Upper / Lower extremities Determine LOC Cranial Nerves Assess PERRLA Glasgow Coma Scale Cardinal Fields of Gaze (6 fields of gaze)
9
Q
What are the components of Sensory perception?
A
PAIN
Superficial and Deep sensation
Light touch
Proprioception- ability to sense stimuli arising within the body regarding position, motion, and equilibrium
10
Q
What does a decrease in mental status of the older adult often mean? And what are important assessments to make?
A
An INFECTIOUS process
Most common site of infection is an UTI.
can also mean hypo or hyper glycemia or hypoxia.
Key early sign of infection is altered LOC.
Assess SpO2, and finger stick blood sugar, signs of infection: fever, sputum production, urine with sediment or odor, red or draining wounds.
11
Q
When are Neuro-Checks completed? What are the 2 rapid neuro assessment tools?
A
Admit to health care facility on an emergent basis, on-going patient assessment, and in event of a sudden change of neurological status.
Rapid assessment tools: Glasgow Coma Scale and PERRLA
12
Q
What is the Glasgow Coma Scale? What are the 3 assessment categories? And the Ranges of the scores?
A
Measures neurological functioning- to determine LOC.
Assessment categories are:
Eye Opening
Motor Response
Verbal Response
Score ranges from 3 (worse-coma) to 15 (normal)
A decrease by 2 points is clinically significant and contact PCP immediately.
13
Q
What is the first category of the GCS?
A
Eye Opening- assess awake and alertness Spontaneous 4 Sound 3 Pain 2 Never 1
14
Q
What is the 2nd category of GCS?
A
Motor Response
Obeys Commands 6 Localizes Pain 5 Normal Flexion (withdrawal) 4 Abnormal Flexion 3 Extension 2 None 1
15
Q
What is the 3rd category of GCS?
A
Verbal Response- whether or not they are oriented
Oriented 5 Confused conversation 4 Inappropriate words 3 Incomprehensible sounds 2 None 1
16
Q
What are signs of altered cognition?
A
HA Restlessness Irritability Unusual quietness Slurred Speech Changes in level of orientation
17
Q
What is decerebrate and decorticate posturing? And what are each associated with?
A
Decerebrate posturing is outward Flexion (more severe)- associated with dysfunction of the brainstem area
Decorticate posturing is inward Flexion- associated with interruptions of the corticospinal pathways
18
Q
What is decerebrate or decorticate posturing and pinpoint or dilated nonreactive pupils, a LATE sign of?
A
They are a late sign of Neurologic deterioration.
19
Q
What is one of the first priorities in head trauma or multiple injuries?
A
Rule out cervical spine fracture.
Assess C-Spine!!!
20
Q
What is ALERT?
A
Awake and Oriented
21
Q
What is Lethargic?
A
Drowsy but easily awakened
22
Q
What is stuporous?
A
One who is arouse with only vigorous or painful stimulation.
23
Q
What is comatose?
A
Patient who is unconscious and unable to arouse.
24
Q
What are Nervous System changes related to AGING?
A
Slower Processing TIME Recent MEMORY loss Decreased Sensory perception to TOUCH Change in perception of PAIN Change in SLEEP patterns Altered BALANCE and COORDINATION Increased risk for INFECTION
25
What are quality improvement measures to promote adequate sleep?
Noise meters-
reduce noise, decrease lighting, and prioritize/cluster care during hours of sleep.
26
What does PERRLA mean?
Pupils Equal Round Reactive to Light and Accommodation
Cranial Nerve 3- oculomotor nerve
Complete test in dim lighting
27
What is Babinski's signs?
Dorsal Flexion of the great toes and fanning of the other toes
Abnormal in anyone over the age of 2, and is a sign of CNS disease.
Positive Babinski's - aka Upgoing
Negative Babinski's - aka Down going
Can occur with drug and alcohol intoxication or after a seizure or in puts with MS or liver disease.
28
What does hyperactive reflexes mean?
indicate possible upper motor neuron disease, tetanus, or hypocalcemia.
29
What can hypo active reflexes mean?
may result from lower motor neuron disease (damage to the spinal cord), disease of the neuromuscular junction, muscle disease, or health problems such as diabetes mellitus, hypothyroidism, or hypokalemia
30
What is FAST?
tool use to recognize a stroke
F- facial symmetry, smile, stick out tongue
A- Arms: can the pt raise both arms equally?
S- Speech: is it slurred? Can the client make a sentence? -- Used for recognition and recall
T- Time: get help now, Small window of time for intervention. Or AAO assessment.
Time is brain cells!!
31
What are the 3 steps to stroke recognition?
Step 1: ask the person to smile and stick out their tongue
Step 2: Ask the pt to make a complete sentence
Step 3: Ask the pt to raise both arms.
Get Help
32
What is a cerebral angiography used for?
A cerebral angiography is used to detect blockages in the arteries or veins in the brain, head, or neck.
Completed with contrast dye, assess allergies to iodine.
Diagnostic gold standard.
33
What are precautions taken for iodine or osmolar contrast agents?
Informed Consent is needed.
Assess allergies, especially to iodine
Cautioned in renal disease, diabetic nephropathy, HF, dehydration, old age, drug interactions such as NSAIDs or metformin, previously administered contrast within 72 hours.
Assess kidney function prior to contrast use.
34
What is a Lumbar Puncture?
A Lumbar puncture requires insertion of a spinal needle into teh subarachnoid space between the 3rd and 5th lumbar vertebrae.
LP is uses to obtain CSF pressure readings with a manometer, obtain CSF for analysis, check for spinal blockage caused by a spinal cord lesion, inject contrast medium or air for diagnostic study, inject spinal anesthetics, or inject selected drugs.
Not recommended for severe ICP.
Pt will be in fetal side-lying position to separate the vertebrae
Discomfort may be felt- shooting or tingling sensation.
Instruct pt to NOT MOVE.
3-5 tubes of CSF are collected.
Post procedure: lay flat or prone for 4-8 hours and may experience a HA, if it doesn't go away after medication- notify the physician. Increase fluid intake. Maintain bed rest. Check LP site for leakage.
35
What are normal Cerebral Spinal Fluid findings? (CSF)
Less than 20cm H20 of pressure
Clear and colorless
0-5 small lymphocytes/mm3 is normal
15-45mg/dL of protein is normal, up to 70 in older adults
Albumin/Globulin ration 8:1
Glucose 50-75mg/dL or 60-70 percent of blood glucose level is normal
36
What is an EEG used for?
An Electroencephalography records the electrical activity of the cerebral hemispheres.
Make sure the hair is clean and free of products.
Avoid the use of stimulants and sedatives within 12-24 hours of procedure.
Do not FAST, can cause hypoglycemia
Ensure quiet room with sign to ensure people know.
37
What is an EMG used for?
An Electromyography (EMG) is used to identify nerve and muscle disorders and spinal cord disease.
Especially used for Multiple Sclerosis and Mysthasia Gravis
38
What is the frontal lobe responsible for?
The frontal lobe is responsible for decisions, thinking, emotions, personality, and Broca's- ability to speak.
39
What is the Parietal Lobe responsible for?
The Parietal lobe is responsible for:
Touch
Feel
Pain.
40
What is the Temporal lobe responsible for?
```
The temporal lobe is responsible for:
Hearing
Smell
Short term memory
Wernicke's- the ability to understand language
```
41
What is the Occipital Lobe responsible for?
The occipital lobe is responsible for:
| The ability to see (vision)
42
What is the Limbic lobe for?
The Limbic lobe is responsible for:
Emotional and visceral patterns of survival
Learning and memory
43
What is the Medulla responsible for?
The medulla is responsible for:
Cardiac-slowing center
Respiratory center
Cranial nerves 9-12
44
What is the Circle of Willis?
The circle of Willis is a ring at the base of the brain where the anterior, middle, and posterior cerebral arteries are joined together.
45
```
Question: the most common cause of changes in the older patient's mental state is:
A. Infection
B. Sedatives
C. Hypoxia
D. Electrolyte imbalance
```
A. Infection-- UTI is most common in the Elderly.
46
Question: A 27 yr old male suffered a frontal lobe infarction secondary to a car crash. What is the appropriate intervention?
A. Enable the bed alarm safety system
B. Place all items in front of the patient
C. Use a picture board with communication
D. Instruct to use the call light prior to getting out of bed.
A. Enable the bed alarm safety system-- the frontal lobe is responsible for decisions/comprehension, thinking, emotions/mood, ability to speak.
47
What is the normal ICP range?
The normal Intracranial Pressure range is 10-15.
Considered ELEVATED if greater than 20 sustained.
48
What factors can influence ICP?
Arterial / Venous Pressure (BP)
Intrabdominal and intrathoracic pressure (coughing, sneezing, straining)
Posture- lay down to decrease ICP
Temperature
Blood gases (increased CO2 or decreased O2)
Cushing's triad: increased pulse pressure (BP), decreased pulse, and irregular respirations
49
What are the components of the Brain?
The components of the brain include:
Cerebral spinal fluid- 10 percent
Intravascular blood- 12 percent
Brain tissue- 78 percent
Also includes the skull
Changes in any one component results in Increased intracranial Pressure
50
What is cerebral blood flow?
The amount of blood in milliliters passing through 100 grams of brain tissue in 1 minute.
The normal cerebral blood flow is approx. 50mL per 100 grams of brain tissue.
51
What is normal cerebral perfusion pressure?
The normal cerebral perfusion pressure is:
70-100 mmHg
Less than 55 mmHg is associated with ischemia and neuronal death.
52
What factors can affect cerebral blood vessels?
Increase in CO2 = vessel dilation = increased ICP
Decrease in O2 = edema = increased ICP
Hydrogen ion concentration = anaerobic metabolism, Acidosis = decreased O2, Alkalosis = increased CO2
53
What can cause increased intracranial pressure?
Increased ICP is life threatening and can result in brain death
An increase in any of the three components (brain tissue, blood, or CSF) can result in increased ICP.
Increased cerebral edema (caused by hypoxia) can also result in increased ICP.
54
What is the pathophysiology of ICP?
Insult to the brain - tissue edema - does not = ICP - Compression of the ventricles - Compression of the blood vessels - decreased cerebral blood flow - decreased O2 with death of brain cells - edema build up around the necrotic tissue - increased ICP with compression of brain stem and respiratory center - accumulation of O2 - vasodilation - increased ICP resulting from increased blood volume - DEATH.
55
What is a migraine headache?
Recurrent episodic attacks of head pain, lasting 4-72 hours.
Throbbing and unilateral
Accompanied by nausea and sensitivity to light, sound, and movement.
At greater risk for stroke and epilepsy.
Most common in women.
56
What are factors that can trigger a migraine attack?
```
Alcohol
caffeine
Aged Cheese
foods with tyramine
chocolate
foods with yeast
MSG
Nitrates
Nuts
Artificial sweeteners
Smoked fish
Stress
Fatigue
Anger
Conflict
Missed meals/hypoglycemia
Smoking/tobacco
Traveling
Sleep problems
```
57
What are common medications that trigger migraines?
Cimetidine (Tagamet)
Estrogen
Nitroglycerin
Nifedipine (Procardia)
58
What are medications used to treat migraines?
```
Acetaminophen,
NSAIDs,
Ergotamine,
Beta Blockers (Propanolol, timolol)
CCBs (verapamil)
Triptans (activate Serotonin receptors),
midrin,
Antiepileptic drugs (depakote, topamax)
```
Tristan's, Ergotamines, and Midrin can cause a rebound HA aka medication overdose HA
Tylenol and Motrin are used for mild migraines
CCBs, BBs, ergotamine, triptans, Midrin are used for severe migrianes
NSAIDs, AEDs,CCBs and BBs are used for preventative therapy drugs.
59
What are the 3 categories of Migraines?
Migraines with an Aura (classic migraine)
Migraine without an Aura (common migraine)
Atypical Migraine
60
What are assessment findings for a Migraine with an Aura? (Classic Migraine) And the phases?
Phase One: Prodrome Phase-
Aura develops over minutes, up to one hour
Pain followed by: Visual disturbance/Flashing lights /Lines or spots/Shimmering/zigzag lines
Numbness, tingling, Acute confusion, Aphasia- difficulty speaking , Vertigo, Unilateral weakness, Drowsiness
Phase Two:
HA accompanied by N/V
Pain beginning in the temple, throbbing in 1 hour
Phase Three:
Pain changes from throbbing to dull
HA/N/V last 4-72 hours
Older pt may have aura without pain- aka Visual migraine
61
What are assessment findings for a migraine without an Aura? (Common Migraine)
Pain is aggravated by performing routine physical activities, unilateral and pulsating
One of these symptoms are present:
N/V
Photophobia
Phonophobia
HA lasts 4-72 hours, often occurs in the early morning during periods of stress, premenstrual tension, or fluid retention
62
What are assessment findings for an Atypical Migraine? And the types?
Status Migrainous:
HA last longer than 72 hours
Migrainous Infarction:
Neurologic symptoms are not completely reversible within 7 days
Ischemic infarct is noted on neuro-imaging
Unclassified:
HA does not fulfill all the criteria to be classified as a migraine
63
What is the only therapy approved for CHRONIC migraine in adults?
Botox
64
What are complementary and alternative therapy for migraines?
```
Yoga
Meditation
Massage
Exercise
Biofeedback
Acupuncture
Herbals
Supplements include: vitamin B12, CoQ10, and magnesium
```
65
```
Question: The nurse is preparing a teaching plan for a client with migraine headaches. Which of these foods may trigger a migraine?
A. Salt
B. Sugar
C. Tyramine
D. Glutamine
```
C. Tyramine
66
What are cluster headaches?
Cluster HA are manifested by brief 30 minutes-2 hour, intense unilateral pain that generally occurs in the spring or fall without warning.
Most common chronic short-duration HA with pain lasting less than 4 hours.
More common in men between 20-50 yrs.
Neuroimaging studies indicate cluster headaches are related to an overactive and enlarged hypothalamus.
HAs occur the same time daily for 4-12 wks and remission for 9 months to 1 year.
67
What are nursing assessments for cluster headaches?
HA usually occurs with Ipsilateral (same side) tearing of the eyes, rhinorrhea (runny nose), Ptosis (drooping eyelid), eyelid edema, facial sweating, and Miosis (constriction of pupils)
Question prescription drugs and OTCs and herbals
Assess recent activity and changes in lifestyle
Explore onset with relationship to emotional and behavioral precipitating factors (bursts of anger, prolonged anticipation, excessive physical activity, excitement)
Identify sleep pattern
Pt often paces, walks, or sits and rocks during an attack
68
What are nursing interventions for cluster headaches?
Importance of Consistent sleep cycle
Same medications as migraine plus lithium and corticosteroids, OTC civamide, melatonin, and glucosamine.
Wear sunglasses and sit away from Windows during an attack
O2 via mask at 12 L for 15-20 minutes
Surgery recommended for Chronic drug-resistant cluster HA. Last resort- PSR or deep brain stimulation.
69
What is a generalized seizure?
A generalized seizure may occur in adults and involves both hemispheres. aka tonic-clonic seizure. MOST SEVERE
Lasts 2-5 minutes; starts with
tonic phase: nuchal rigidity, loss of consciousness.
Clonic (rhythmic) phase: jerking of extremities, may bite tongue or incontinent. Fatigue, acute confusion, lethargy (last up to 1 hour after the seizure).
70
What is pre-ichtal and post-ichtal?
Pre-Ichtal: has an aura before the seizure occurs.
Post-Ichtal: after the seizure is over. A state of extreme exhaustion and lethargy. Pt still at risk for injury.
71
What is a partial seizure? And what are the classifications of a partial seizure?
A partial seizure is also called a focal or local seizure, occurring in one hemisphere.
Complex Partial: cause loss of consciousness (syncope or blacking out) for 1-3 minutes, automatisms may occur (unaware of environment) and may have loss of memory (amnesia).
Commonly occurs in the temporal lobe- psychomotor seizures.
Simple Partial: Remains conscious, aura involved- Deja vu phenomenon, offensive smell, sudden pain. May have one-sided movement of extremity, unusual sensations, autonomic changes IN HR, skin flushing, and epigastric discomfort.
72
What are unclassified seizures?
Unclassified or idiopathic seizures account for half of all seizure activity.
Occur for no reason and do not fit into generalized or partial classifications.
73
What are secondary seizures?
Secondary seizures result from an underlying brain lesson, most commonly a tumor or trauma.
```
May be caused by:
metabolic disorders,
acute alcohol withdrawal,
electrolyte imbalances- hyperkalemia, water intoxication, hypoglycemia.
High fever
Stroke
Head injury
Substance abuse
HR disease.
```
Secondary seizures are NOT considered epilepsy.
These can also be considered risk factors for seizures.
74
What type of seizure is most common in older adults? And what is commonly associated with seizures in older adults?
The most common type of seizure in older adults is Complex partial seizures.
Seizures in older adults are commonly associated with: HTN, cardiac disease, DM, stroke, dementia, and recent brain injury.
75
What are some considerations regarding epilepsy women?
Hormone changes from menstrual cycles and oral contraceptives in conjunction with Antiepilectic drugs require MORE frequent monitoring for drug effectiveness.
Teratogenic risks associated with AEDs.
AEDs also contribute to osteoporosis in menopausal women.
76
What are common seizure precautions? What should NOT be at the bedside, as it can result in injury?
```
Seizure precautions include:
Oxygen
Suction Equipment
Airway
IV access
Side rails up and padded or place mattress on floor.
```
NO padded tongue blade-- more likely to chip a tooth or increase risk for aspiration.
77
What are some Antiepileptic drugs (aka anticonvulsants) used for ACUTE seizure management?
Lorazepam (Ativan)- Monitor ABCs. 4mg over 2 minutes, can give up to 8mg.
Diazepam (Valium)- monitor ABCs.
Diastat (rectual Valium)- monitor ABCs.
IV Phenytoin (Dilantin) or fosphenytoin (Cerebryx)- Monitor GI distress, gingival hyperplasia, anemia, nystagmus. Check CBC and Ca level. Therapeutic range: 10-20; toxic if greater than 30. Give up to 50mg/min. Fosphenytoin is water soluble, causes fewer cardiac complications, compatible with more IV fluids, give at rate 100-150mg/min. Assess labs q6-12 hours after loading dose, then 2 wks after PO dose started.
78
What are common medications use for LONG-TERM seizure management? And what are some nursing interventions associated with each med?
Carbamazepine (tegretol)- T-C seizure; monitor HA, N/V, blurred vision. CBC. No crush or chew.
Clonazepam (Klonopin)- Absent seizure. Monitor liver function
Divalproex (Depakote)- all seizures; watch N/V, rash, lethargy, anorexia. CBC and liver function.
Lamotrigine (Lamictal)- Partial seizures; Diplopoda (double vision), HA, Dizzy, drowsiness, life-threatening rash when given with valproic acid.
Levetiracetam (Keppra)- adjunct partial seizure; monitor renal function, notify PCP if gait disturbance.
79
What is self-management education regarding seizures?
Educate the pt and family on:
- understanding the med orders
- Emphasize not to stop AEDs even if seizures stop; d/c can lead to life threatening status epilepticus.
- Balanced diet, rest, stress reduction techniques. Keep seizure diary.
- NO OTCs or herbals without talking to PCP. NO alcohol.
- Wear medic alert bracelet
- Follow ups, lab tests Important
- Social services resources- refer to epilepsy foundation.
- Employment safety- cannot discriminate
- Vocational rehabilitation
80
What is EBP care for tonic-clonic or partial seizures?
```
Protect the patient from INJURY.
NOTHING in mouth.
Turn pt to SIDE LYING position to keep airway clear.
LOOSEN tight clothes
Maintain PATENT AIRWAY
NO restraints
RECORD length of seizure
```
81
At completion of a seizure, what are some cares to complete?
```
Assess VS
Perform Neuro check
Keep patient on side
Allow rest
DOCUMENT seizure
```
82
What is included when documenting a seizure?
```
How often seizures occur
Describe each seizure
Did more than one type occur
Any observations noted during seizure
How long the seizure lasted
When the seizure took place
Whether the seizure was proceeded by an aura
What the pt does after the seizure
How long it takes for the pt to return to pre-seizure state
```
83
What is status epilepticus? What are common causes of status epilepticus? What are nursing interventions for status epilepticus?
Status epilepticus is a prolonged seizure lasting longer than 5 minutes or repeated seizures over 30 minutes. This is a medical EMERGENCY.
Seizures last longer than 10 minutes can cause DEATH.
```
Common causes:
Sudden withdrawal of AEDs
Infection
Acute alcohol or drug withdrawal
Head trauma
Cerebral edema
Metabolic disturbances
```
Interventions:
Establish airway
ABGs
IV push Lorazepam or diazepam; if no line give IM
Rectal diastat
Loading dose of phenytoin- no more than 50mg/min
84
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Question: A client with a history of seizures is placed on seizure precautions. What emergency equipment will teh nurse provide at the bedside?
A. Oropharyngeal airway
B. O2
C. NG tube
D. Suction
E. Padded tongue blades
```
A. Oropharyngeal airway
B. O2
D. Suction
85
What is epilepsy? And what are the 2 subcategories?
Epilepsy is 2 or more seizures experienced in a life-time.
Primary epilepsy: expected, with a known diagnosis of epilepsy.
Idiopathic epilepsy: has a seizure, but with unknown origin such as acute illness.
86
What are some considerations for Antiepileptic drugs (AEDs)?
Evaluate blood level regularly
Drug2drug or drug2food interactions- citrus juices- especially grapefruit juice
NO warfarin with phenytoin
Document
87
What surgical manage to can be done for seizures?
Vagel Nerve stimulation (VNS)- TENS unit for brain
Ablation- burn misfiring nerves.
WADA test- intracarotid amobarbital (anesthetic)
SPECT/PET scans
Partial corpus callosotomy- suctioning 2/3 of anterior lobe
88
What is meningitis? What are the different types of meningitis?
Meningitis is an inflammation of the meninges (the protective membrane around the spinal cord and brain)
Types:
viral- most common- sources: Hib, Mumps, Varicella, Herpes, HIV.
Bacterial- most deadly- sources: sinuses, abscess, facial trauma
fungal- source: AIDS.
Protozoal
Bacterial meningitis is the most deadly- usually within 24 hours; common in confined spaces such as dorm rooms and military quarters
89
What is the age range of people at highest rate of meningococcal infection?
People ages 16-21 are at the highest rate of meningococcal infections that are life-threatening.
The CDC recommends meningococcal vaccine between the ages 11-12 yrs with a booster at 16 yrs.
An additional booster is recommended for adults if living in shared residence or are immunocompromised
Can get a booster as early as 8 weeks after initial vaccine.
90
What are assessment findings (symptoms) of meningitis?
FEVER and chills
Headache- sever, unrelenting
Photophobia (light)
Phonophobia (sound)
Indications of ICP: altered LOC, Cushings triad
Nuchal rigidity
Positive Kernig's sign (bend hip, legs can't go straight up)
Brudzinski's sign (bend neck, hips flex)
Decreased mental status and short attention span
Focal deficits- seizures.
Myalgia (muscle aches)
Red MACULAR rash
Pain with neck movement, especially chin to chest (can't do)
91
What are interventions for meningitis?
CSF testing- used to Dx meningitis
CBC- WBC elevated ; grams stain and CNS (bacterial)
CT/XCR
PREVENTING- is vaccinations
Hand washing- maintaining; National patient safety goal
Most important- Monitor and document q4hr (look for early neuro changes)
Risk for seizure- use precautions
Damage to cranial nerve 6- can cause hydrocephalus- ICP and urine Incontinence.
92
What are lab findings of Cerebral Spinal Fluid (CSF) for bacterial meningitis and viral meningitis?
Bacterial meningitis- cloudy, turbid appearance; increased WBCs and Protein; decreased glucose; elevated CSF pressure.
Viral meningitis- clear appearance; increased WBCs; slight increase protein; Normal glucose (slight decrease possible); normal or elevated CSF pressure.
93
How are seizures associated with meningitis?
Seizure activity is caused by inflammation of the meninges which spreads to the cerebral cortex. --- this leads to abnormal stimulation of the hypothalamus. --- which causes excess of AntiDiuretic Hormone (ADH) (vasopressin). ---- which leads to water retention and decreased Na. --- caused by increased Na loss by the kidneys. (SIADH)--- which leads to INCREASED ICP.
94
What is SIRS (systemic inflammatory response syndrome)?
SIRS (systemic inflammatory response syndrome) is a reaction to endotoxins caused by a bacterial infection.
I.e.: Bacterial Meningitis
Associated with a rapidly falling BP and tachycardia.
Observe vascular status by observing the extremities, peripheral pulses, and abnormal bleeding.
95
What nursing interventions when caring for a patient with Meningitis?
When caring for a patient with meningitis:
Monitor ABCs
Neuro checks q2-4 hours
Assess cranial nerves: 3,4,6,7,8
Assess Vascular function
Give drugs and IV fluids: broad-spectrum ABX started w/in 1-2hrs.
Monitor labs
Reposition q2 hours
ROM exercises q4 hours
Decrease stimulation: dim lights, bed rest
DROPLET precautions: stay 3 ft away unless wearing a mask, pt wear mask outside of room, educate visitors.
Prevent complications such as: increased ICP, electrolyte imbalance, seizure, shock, vascular dysfunction.
96
What medications are used to treat increased ICP?
Mannitol
Hyper osmolar agents
Antiepileptic drugs
Steroids are recommended for patients with S. Pneumoniae meningitis.
97
What medications should be given prophylactically to treat N. Meningitidis?
Rifampin
Ciprofloxacin (Cipro)
Ceftriaxone (Rocephin)
98
What medications are prescribed for those in close contact with someone diagnosed with H. Influenza meningitis?
Someone in close contact with a person diagnosed with H. Influenza meningitis should be given:
RIFAMPIN
99
What are the 2 types of bacterial meningitis that require DROPLET precaution? (Transmission based precautions)
N. Meningitides and H. Influenza meningitis both require DROPLET PRECAUTIONS
100
What is encephalitis? And what are the different types of transmission?
Encephalitis is an inflammation of the brain stem and meninges. --- often affects the cerebrum, the brain stem, and the cerebellum.
Viral transmission is most life-threatening -- does NOT cause exudate (PUS) formation.
Arbovirus: transmission through infectee mosquito or tick--- WEST NILE
-Incubation of West Nile is 2-15 days
Diagnostic tests: Enzyme assay and West Nile immunoglobulin M (IgM) or CSF.
101
What are symptoms of viral encephalitis, caused by West Nile?
No symptoms or mild-flu like: fever, body aches, N/V)
```
Serious Symptoms include:
High Fever
Severe HA
Decreased LOC
Tremors
Vision Loss
Seizures
Muscle weakness or paralysis
```
102
What are COMMON signs and symptoms of encephalitis?
```
High fever
N/V
Nuchal rigidity (stiff neck)
Change in LOC- agitation, acute confusion, irritability
Dysphagia (difficulty swallowing), mild weakness to hemiplegia
Focal Neurologic deficits- seizures
Photophobia
Phonophobia
Fatigue
Symptoms of increased ICP
Joint pain
HA
Vertigo
Tremors, spasticity, ataxic gait
Increased Deep tendon reflexes
Ocular palsies (paralysis)
Facial weakness, nystagmus
```
103
What are clinical manifestations of Herpes caused encephalitis?
Herpes Zoster affecting the cranial and spinal nerve, clinically manifests as:
Rash
SEVERE PAIN
Itching
Burning
Tingling in areas innervated by the nerves
104
How can you educate patients and their families on protection from the West Nile Virus?
Educate patients and their families on:
Limiting their time outside between dawn and dusk
We are protective clothing such as long sleeves and pants
Use insect repellant containing DEET
Check Windows and screens for holes to repair
Remove free standing water
keep pools and hot tubs clean and chlorinated
105
What are signs that require IMMEDIATE notification to the PCP, in cases of severe encephalitis?
Cases of severe encephalitis where nonverbal or comatose is baseline, MONITOR VS and PUPILS is critical to monitor Neuro changes...
```
Immediately report:
Widening pulse pressure
New bradycardia
Irregular respiratory efforts
Increased dilating pupils, less responsive to light
```
106
What are nursing interventions for a pt with encephalitis?
Acyclovir (Zovirax) is drug of choice, begin it early before pt is stuporous or comatose --- neuro decline is usually 4-6 days.
Maintain a patent airway to prevent development of atelectasis or PNA
Delegate to CNA to T,C,DB pt q2 hours
Assess VS and neuro cheek q2 hours
Elevate HOB 30-45 degrees unless contraindicated
Keep room dark and quite, keep bed in low position
Family support- to understand cares, fearful of not returning to baseline.
Other nursing interventions similar to that of meningitis cares: broad spectrum ABX, assessments, I/O's, weight, labs, ROM, bedrest.
107
Where are patients with permanent neuro deficits and encephalitis discharged to? Where are patients with minimal neuro deficits discharged to?
Permanent neuro defects:
Rehab facility or long-term care
Minimal neuro defects:
Home
108
What is Parkinson's Disease? Aka paralysis agitans
Parkinson's disease is a progressive neuro degenerative disease, common in older adults.
```
4 Cardinal signs:
Tremors
Muscle rigidity
Bradykinesia or akinesia (slow movement or no movement)
Postural instability
```
Primary- idiopathic
Secondary- caused by brain tumor or antipsychotic drugs
Parkinson's disease is caused by a lack of dopamine and too much Acetylcholine -- leads to an inability to control voluntary movements-- reduces the Sympathetic Nervous System (rest and digest) results in orthodontic hypotension.
Tend to have familial trend, associated with mitochondrial DNA-- destructs dopamine producing cells
50 percent more in men than women
109
What are the stages of Parkinson's disease?
Stage 1: INITIAL stage- unilateral limb movement, minimal weakness, hand/arm trembling
Stage 2: MILD stage- bilateral limb involvement, mask-like face, slow-shuffling gait
Stage 3: MODERATE stage- postural instability, and increased gait disturbances
Stage 4: SEVERE disability- Akinesia and rigidity
Stage 5: COMPLETE ADL dependence
110
What are assessment findings in Parkinson's Disease?
Stooped posture, Flexed trunk
Slow shuffling gait, propulsive gait
Bradykinesia, muscle rigidity, tremors
pill rolling movement, dysphagia
uncontrolled drooling
Fatigue
macrographia
Hypophonia (soft,low pitch voice), dysarthria (slurred speech), echolalia (automatic repetition)
Orthodontic hypotension, excess perspiration, flushing
Emotionally Labile, depressed, paranoid, rapid mood swings
dementia or delirium, delayed reaction time, sleep disturbances
111
What are nursing interventions for a patient with Parkinson's disease?
```
Allow extra time to respond
Administer medications, including pain
Monitor side effects of medications
Physical and Occupational therapy
Extra time for ADLs
Schedule appointments and therapy late morning
Prevent complications of immobility
Speak slow and clear
Assess ability to eat and swallow
High protein, high calorie foods to maintain weight
Assess sense of self body image
Assess depression, anxiety, and insomnia
```
112
What are common Parkinson's medications?
```
dopamine agonists (3-5 years most affective)
-apomorphine, pramipexole, ropinirole (Requip)
```
Sinemet (levodopa-carbidopa drugs)
COMTs inhibitors - entacapone (Comtan)
MAOIs- rasagiline mesylate (Azilect) --- avoid foods with tyramine
Bromocriptine mesylate (Parlodel)--- when others less effective
Symmetrel- antiviral
Cholinesterase Inhibitor- Rivastigmine (Exelon) for dementia
113
What is dementia? aka Alzheimer's disease... What impairments qualify for a diagnosis of dementia?
dementia is a loss of brain function that is chronic and progressive. It affects the ability to learn and impairs language, judgment, and behavior.
Alzheimer's disease is the most common, affects people over the age of 65.
Early onset or vascular dementia occurs in people ages 40-50.
A patient must have at least 2 significant impairments in:
Memory, communication, language, attention span, reasoning, judgment, and visual perceptions.
114
What are age changes in the elderly?
The brain of elderly weighs less and occupies less space.
If dementia- marked atrophy and loss of cortical neurons; neurofibrillary tangles (tangles masses of fibrous tissue in the neurons) and Neuritic plaques (deterioration of nerve terminals)
115
What is the etiology and genetic risks of Alzheimer's disease?
Etiology is unknown. Often a family history.
American Americans- greater risk for developing Alzheimer's disease
Hispanics- tend to develop Alzheimer's disease earlier in life.
Environmental agents: Herpes zoster, herpes simplex, toxic metals (zinc and copper), head trauma or head injury.
116
What is some health promotion for Alzheimer's disease?
eat a well balanced diet
Eat/drink dark colored fruits and vegetables
Use soy products
Consume folate and vitamins B12, C, and E.
Exercise such as walking and swimming.
117
What are common causes of cognitive impairment in older adults?
Neurologic- vascular insufficiency, infections, trauma, tumors.
Cardiovascular- MI, dysrhythmias, HF, cardiogenic shock, stroke, endocarditis.
Pulmonary- infection, PNA, hyperventilation
Metabolic- Electrolyte imbalance, Acidosis, Alkalosis, Kidney failure, UTI, hepatic failure.
Drug intoxication- misuse of med, side effects, ingestion of heavy metal
Nutritional- B vitamins, Vitamin C, hypoproteinemia
environmental- hypo/hyper-thermia, unfamiliar environment, sensory deprivation
Psychological- depression, anxiety, pain, fatigue, grief, paranoia
118
What are assessment findings of Early (stage 1) Alzheimer's disease?
First symptoms up to 4 years:
Independent, no social or employment problems
Denies presence
Forgets name or misplaces household items
Short-term memory loss (FIRST SIGN OF ALZHEIMER'S)
Small changes in personality or behaviors
Loss of initiative
Mild impairment of cognition and judgement
Decreased performance
Unable to travel alone
Decreased sense of smell
119
What are assessment findings for Moderate (Stage 2) Alzheimer's disease?
```
Seen for 2-3 years:
Impairment of all cognitive functions
Unable to handle finances or money
Disoriented to time, place and event
Depression and agitation
Increasingly dependent on ADLs
Difficulty driving, getting lost
Speech and language deficits: Less talkative, decreased vocabulary
Incontience
-apraxia (inability to use words/objects)
-aphasia (inability to speak)
-anomia (inability to find words)
Wandering, trouble sleeping
```
120
What are assessment findings for Late (stage 3) Alzheimer's?
```
Completely incapacitated, bedridden
totally dependent in ADLs
Motor and Verbal skills LOST
General and Focal Neurologic deficits
Agnosia (loss of facial recognition)
```
121
What are some assessment tools used for dementia? Briefly describe them...
Folstein's Mini Mental State Exam- used to determine onset and severity of cognitive impairment. (MMSE)
MMSE- assesses 5 major areas- orientation, registration, attention and calculation, recall, and speech-language. Score ranges from 0-30, teh lower the score the greater the severity of dementia.
Set test- quicker screening test- ask pt to name 10 items in 4 categories: (FACT) fruits, animals, colors, towns. 1 point for each item is given, maximum score of 40. Score above 25 does not have dementia.
122
What factors can worsen dementia and Alzheimer's disease?
```
Stroke, MI
Subdural Hematoma
Tumor
Decreased blood supply to the brain
Dysrhythmias
Hypoglycemia
Impaired renal or hepatic function
Infection
Impaired vision and hearing
Sudden changes in surroundings
Pain and discomfort
Drugs
Physical and chemical restraints
```
123
What are some nursing interventions for Alzheimer's Disease?
Place picture of pt on room door
Adequate, no glaring lighting
Promote adequate, undisturbed sleep
Keep furniture and personal belongings in the same place
Keep pictures of family and friends around with labeling
Clocks and single date calendars used
Reality orientation for early onset
Validation therapy for moderate or severe Alzheimer's
Encourage as much self care as possible
OT/PT
Adaptive devices- grab bar, BSC, adapting eating utensils
Toilet program q2hr
Encourage fluids
AVOID restraints, including side rails
Redirection- short, clear sentences, one task at a time, verbal ques
RESTLESSNESS- may indicate urine retention, pain, infection, hypoxia
Drug therapy-
Cholinesterase Inhibitors: donepezil (Aricept), galantamine (Reminyl), rivastigmine (Exelon).
NMDA receptor antagonists: block glutamate (Namenda)
Antidepressants: SSRIs paroxetine (Paxil) and sertraline (Zoloft)
do NOT use Tricyclic Antidepressants: amitriptyline (Elavil) because of anticholinergic effects
Psychotropic drugs for emotional and behavioral problems
124
What are last resort restraints acceptable in long-term care?
Waist belts
Geri-chairs
Lap boards
All pt have the right to remain free of physical and chemical restraints- Joint Commission require alternative measures be taken before resorting to any physical or chemical restraints.
125
What are some approaches to preventing and managing wandering patients?
Identify the most at risk
Provide appropriate supervision and frequent checks
keep pt in areas with maximum observation, not at nurses station
Keep away from elevator or stairs
Do not change rooms, will cause confusion
Avoid chemical and physical restraints
Assess and treat pain
Use re-orientation and validation therapy
Frequent toileting or incontinence care
Prevent overstimulation
126
What are tips for minimizing behavioral problems at home?
Remove small area rugs, replace floor with non-slip flooring
Arrange furniture to maximize safety, minimize clutter
Install night lights, smoke alarms, etc.
Install grab bars in BR, decrease door locks
Single date calendars and large faced clocks
Explain activities immediately before, use simple instructions
Hang complete outfits together
Develop a predictable routine
When problems occur, redirect to another activity
Small crowds or outings, minimize time in large crowds
Arrange for sitter or home care assistance
Register with the Alzheimer's Association Safe return Program
127
What are methods to reduce caregiver stress?
```
Maintain realistic expectations
Take each day one at a time
Find the positive aspects
Use available resources
Explore alternative care settings
Establish Advanced Directives
Set aside time each day for rest and recreation
Seek respite care
Watch your diet, exercise, get plenty of rest.
Be realistic, accept help
Use relaxation techniques
```
128
What is Huntington's Disease?
Huntington's disease is a single gene caused by a mutation on chromosome 4; Cytosine, Adenine, Guanine (CAG)
it's a hereditary disorder, only needing transmission from one parent.
Causes neurological and behavioral problems
If inherited from father: earlier onset and shorter life expectancy
The longer the mutation, the more severe the disease.
129
What are presenting symptoms of Huntington's disease?
```
Gradual onset:
Progressive mental status changes, causing dementia
Choreiform movements (rapid jerking movements in limbs, trunk, and face)
Dementia
Decreased GABA
Increased Glutamate
Poor balance
Hesitant/explosive speech
Dysphagia
Impaired respirations
Incontinence
Decreased attention span
Poor Judgement
Memory loss, personality changes, dementia
```
130
What are the 3 stages of Huntington's disease?
Stage 1: onset of Neurologic or psychological symptoms
Stage 2: characterized by increased dependence on others for cares
Stage 3: results in loss of independent functioning
131
What are some nursing interventions for Huntington's Disease?
Only way to PREVENT Huntington's is to NOT have biological children-- genetic counseling important
First drug to decrease Chorea is Tetrabenazine (Xenazine)-- given orally- depletes monoamines, increased risk for depression and suicide
Educate to report early signs of depression: sleeplessness, decreased appetite, mood changes
Psychotropic agents- manage abnormal movements that interfere with ADLs, help control agitation, hallucinations, or psychotic delusions.
Speech-language therapy, dietary consult and recommendations, PT/OT, case manager and social worker to coordinate care and resources
Huntington's Disease Society of America
132
What is Acute Back Pain and what is Chronic Back Pain?
Acute Back Pain is self-limiting, occurring for a brief period of time.
Chronic Back Pain continues for 3+ months or in repeated episodes
Low Back Pain is the leading cause of work disability--- lumbosacral (lower back) and cervical (neck) are most commonly affected.
Acute back pain results from injury or trauma such a fall, car crash, or lifting heavy objects.
133
What is low back pain?
Low back pain occurs in the lumbosacral area, caused by muscle strain, spasm, ligament sprain, disc degeneration, or herniation.
134
What is a Herniated Nucleus Pulposus? (HNP)
Herniated Nucleus Pulposus occurs in the lumbosacral area pressing on the adjacent spinal nerve (sciatic nerve) causing severe burning or stabbing pain down into the leg or foot. May also experience muscle spasms, numbness, and tingling.
Most often occurs between the 4th and 5th lumbar vertebrae
135
What is Spondylosis? What is Spinal stenosis?
Spondylosis occurs when a vertebrae slips forward onto the vertebrae below it causing pressure on the nerve roots, leading to low back pain, numbness, and tingling into the buttocks, leg or foot.
Spinal stenosis is narrowing of the spinal canal, nerve root canals, or intervertebral foramina; caused by infection, trauma, herniated disks, arthritis, and disc degeneration.
136
What are factors contributing to low back pain?
```
Spinal Stenosis
Hypertrophy of intraspinal ligaments
Osteoarthritis / osteoporosis
Scoliosis / Lordosis
Deminished blood supply to the spinal cord
Blood dyscrasias
Intervertebral disc degeneration
```
Obesity
Smoking
Congenital spinal conditions
vertebral fractures
137
What is health promotion and maintenance for acute back pain? In the workplace?
Acute back pain can be PREVENTED by:
Good posture and exercise
OSHA mandated the development and implementation of a plan to decrease musculoskeletal injuries through ERGONOMICS.
Ergonomics is a science in the workplace designed to increase worker comfort while increasing efficiency and productivity.
I.e.: ceiling lifts
138
What are Prevention measures for low back pain?
```
Use safe manual handling practices
Utilize assistance
Regular exercise program
Do not wear high heels
Use good posture when sitting, standing, and walking
Avoid prolonged sitting or standing
Keep weight within 10 percent of ideal body weight
Ensure adequate Calcium intake.
Stop smoking
```
139
What are some nursing interventions for low back pain?
Acute low back pain has spontaneous resolution within 3-6 months.
Home exercises, PT, and drug therapy.
Williams position: semi-fowlers position with a pillow under the knees or resting in a recliner- relieves pressure off the spine
If standing long periods of time- shoe insoles and floor padding can decrease pain.
Acetaminophen, NSAIDs, muscle relaxants- for acute pain
NSAIDs, opioids, and antidepressants for chronic pain
Heat or cold applications for 20-30 minutes at least 4 times per day
PT- deep heat therapy: phonophoresis (topical gel) followed by ultrasound for 10 minutes; iontophoresis small electrical current and dexamethasone
Complementary therapy- chiropractic or spinal manipulation, acupuncture, herbal medicines, weighted traction
140
What are Minimally Invasive Surgical interventions available for low back pain?
Percutaneous Endoscopic Diskectomy (PED): removal or destruction of disk pieces compressing the nerve.
Thermodiskectomy: shrinking the herniated disk before removal.
Laser assisted Laparoscopic Lumbar Diskectomy: umbilical incisions to remove herniated disks not involving the vertebral canal. Discharge in 23 hrs.
141
What are Conventional Open Surgical interventions for back pain?
Surgical incisions to expose an atomic landmarks
Diskectomy: Removal of a herniated disk
Laminectomy: removal of the laminae and facet joints to obtain access to disk space.
Spinal fusion: (arthrodesis): bone grafting to strengthen an unstable spine. Bone often from iliac crest, intrathecal dose of long-acting morphine to decrease post-op pain.
142
What are Post-op surgical interventions?
Minimally invasive procedures go home within 24 hrs with exercise program.
Conventional Open surgeries: monitored for 24-48 hours. VS q4 hrs.
FEVER and hypotension- indicate bleeding and severe pain.
Assess ability to void- sacral nerve damage or analgesic induced.
Ambulate night of procedure. Control pain with PCA morphine.
ASSESS the dressing for for drainage- if noted NOTIFY the PCP..
Halo test- fold 4x4 into 4's, touch center corner to incision site- if CSF will see differing rings of color
Log Rolling every 2 hours- keep back straight as possible
Early MOBILITY and SCDs are used to prevent VTE.
143
How can you prevent back injury when moving a patient?
Do not lift more than 10 pounds without assistance
Push not pull
Do not twist
Use handle or grips
Avoid sitting or standing for long periods of time
Use proper posture
Do not wear high heels for extended time
Implement OSHA guidelines, improve team communication, Encourage patient participation
144
What is an opioid analgesic that should not be given to anyone with a mental or behavior problem?
Ziconotide - it can cause severe psychosis.
145
What are common interventions used for cervical neck pain?
Often herniated disks caused by muscle strain, aging, poor posturing, RA, osteoarthritis, or infection.
Use a soft collar to stabilize the neck, especially at night-- not to be worn longer than 10 days-- can cause decreased muscle strength and ROM.
Surgery: Anterior Cervical Diskectomy and Fusion: maintain airway and breathing.
146
What are nursing interventions following an Anterior Cervical Diskectomy and Fusion?
```
Priority: Monitor ABCs.
Check for bleeding or drainage
Monitor VS and Neuro-checks
Assess swallow ability
Assess ability to void and I/O's
Manage pain
Ambulate within a few hours
```
147
What is some discharge teaching after an Anterior Cervical Diskectomy and Fusion?
Have someone stay with pt for first few days
Review Drug therapy
No lift, No driving, No strenuous activity
Care of incision
Walk every day
Report numbness, pain or tingling that has gotten worse.
Wear brace/collar as prescribed.
148
What are complications associated with an anterior cervical diskectomy and fusion?
```
Hoarseness
Temporary dysphagia
Spinal cord injury
Tear of the dura
Artery injury
Pseudoarthrosis
Graft or screws lossen
```
149
What are the 5 primary mechanisms that result from a spinal cord injury?
Hyperflexion-forceful acceleration forward (car hit a wall)
Hyperextension- collision from behind (rear-ended by car)
Axial Loading or vertical compression- vertebral shattering: falling from ladder or diving head first into pool
Excessive rotation- head turning beyond normal range- boxers
Penetrating trauma-external factor: stabbing or shooting
150
What is the initial assessment for someone with a spinal cord injury?
```
PRIORITY: assess ABCs
Assess breath sounds q2-4hr
Assess cap refill and pulses
Assess hemorrhage- if hypotension and tachycardia
Glasgow Coma Scale to assess LOC
```
Damage to the cervical or upper thoracic vertebrae causes respiratory impairment; plegia (paralysis) or paresis (weakness)
Hypo or hyper -esthesia (sensation)
Monitor BP- a systolic BP below 90 can cause impaired spinal cord perfusion
Monitor for abd. Pain and. Changes in bowel or bladder- can cause paralytic ileus urinary retention
151
What are NANDA diagnoses associated with spinal cord injury?
Risk for respiratory distress or failure
Potential for cardiovascular instability
Potential for secondary spinal cord injury
Impaired physical mobility
Spastic or flaccid bladder or bowel
152
What are nursing interventions for spinal cord injury?
AIRWAY management is is PRIORITY
Adequate hydration- neurogenic shock may occur within 24 hours with injuries above T6.
NEUROGENIC SHOCK is low BP, low HR, low SpO2
Reduce and immobilize the fracture- inspect skin daily
Assess neuro status q1-4 hrs
Core measures: Compression stockings and low molecular wt Heparin (lovenox)
Halo fixture worn for 8-12 weeks- caution pins loosening, local infection, and scarring.
153
What is Autonomic Dysreflexia? And how does it present?
Autonomic Dysreflexia- hypereflexia- sudden uninhibited sympathetic discharge (fight or flight)
Sudden rise in BP and bradycardia
Profuse sweating above the lesion (face, neck, shoulders)
Flushing of skin ABOVE lesion and pale skin BELOW lesion
Blurred vision
Spots in visual field
Nasal Congestion
Severe throbbing headache
154
What are immediate interventions for Autonomic Dysreflexia?
PRIORITY: sitting or safe position
Notify PCP
Monitor. BP q 10-15 mins
Give Nifedipine or nitrates, recurrent give alpha blocker (terazosin) prophylactically
Check urine retention or catheter blockage- free of kinks
Cathetorize if Bladder distention
Assess bowel or bladder complication: UTI, fecal impaction
Assess for Pressure Ulcer
155
What are teaching needed for self care of a spinal cord injury?
```
Mobility skills and rehab services
Pressure ulcer prevention
ADL skills
Bowel and Bladder program
Prevent autonomic Dysreflexia
```
Health care resources- National Spinal Cord Injury Association
156
What are management options for a spinal cord tumor?
Commonly caused by metastasis to spine
Chemotherapy
Radiation Therapy
157
What is Multiple Sclerosis?
Multiple Sclerosis is a life-long inflammatory disease that effects the brain and spinal cord.
Demyelination- change in the white matter - can be caused by viruses
Occurs between Ages 20-40
158
What are assessment finding of multiple sclerosis?
```
Muscle weakness and spasticity
Intention Tremors (when performing activities)
Dysmetria (unable to direct/limit movement)
Numbness and tingling
Hypalgesia (decrease sensitivity to pain)
Ataxia (decreased motor function)
Dysarthria (slurred speech)
Dysphagia difficulty swallowing)
Diplopia (double vision)
Nystagmus (involuntary eye movement)
Scotomas (change in peripheral vision)
Tinnitus (ringing of the ears)
Vertigo (dizziness)
Bowel/bladder dysfunction
Impotence
Memory loss, impaired judgment, decreased problem solving
Depression
```
Elevated Protein and slightly increased WBCs
MS patients are often weak and easily fatigued.
159
What are medications used to treat Multiple Sclerosis?
Medications used to treat and control the disease, decrease symptoms, and slow the progression
```
Immunoglobulins
Interferon (immunomodulator)
Synthetic protein (Glatiramer)
Antineoplastics
Monoclonal antibody
Corticosteroids
Immunosuppressants
```
Rotate injection site for interferon and Glatiramer, avoid crowds with infections
160
What is patient education for Multiple Sclerosis?
alternative therapies: reflexology, massage, yoga, acupuncture.
Interdisciplinary team approach to rehab and home care. Adapt rooms as disease progresses.
Teach factors that exacerbate the symptoms. Avoid overexertion, stress, extreme temperatures (hot tubs, sauna, excessive chilling), important to take mediations and know side effects.
Home PT, self-care skills, ADLs, nutrition. Balance rest and activities, Coping strategies.
161
What is Amyotrophic Lateral Sclerosis? Aka Lou Gehrig's disease
Upper and lower motor neuron disease of adult onset. Progressive weakness, muscle wasting, and spasticity.
Motor weakness and deterioration including the ability to talk, swallow, and breathe.
Death occurs within 3 years of diagnosis due to Respiratory failure. Commonly affects ages 40-60 yrs.
162
What are clinical manifestations of Amyotrophic Lateral Sclerosis (Lou Gehrig's disease)
```
Tongue atrophy
Weakness of hands and arms
Muscle atrophy beginning in the arms
Fasciculation (twitching of the face or tongue)
Emotional incontinence
Nasal sounding speech
Dysarthria (slurred speech)
Dysphagia (difficulty swallowing)
Fatigue while talking
Stiff or clumsy gait
Abnormal reflexes
```
Increased Creatinine Kinase (CK)
163
What are some interventions for Lou Gehrig's Disease?
Riluzole- only FDA approved for ALS patients- take on an EMPTY stomach
S/Sx of liver toxicity: vomiting and jaundice
Drug therapy for pain, fatigue, spasticity, excess secretions, sleep disturbances
PT/OT
Palliative Care for symptom management
164
What is Guillain-Barre Syndrome?
Guillian-Barre syndrome is an acute inflammatory process, causing demyelination of the peripheral nerves- causing motor weakness and pain
Antibodies attach the myelin sheath surrounding the axons.
Ascending paralysis- symptoms begin in the legs and progress to the arms, may require mechanical ventilation if diaphragm affected.
Healing occurs in reverse, head to toe.
Diagnose with LP and CSF- high protein (peaks in 4-6 weeks) and normal WBCs.
165
What are the three stages of acute Guillain-Barre Syndrome?
Stage 1: Acute or Initial: 1-4 weeks, beginning of onset of first symptoms and ends when no further deterioration occurs.
Stage 2: Plateau period: lasts several days to 2 weeks: no progression is made
Stage 3: Recovery phase: occurs gradually over 4-6 months, up to 2 years- Remylination and axon regeneration.
If permanent damage occurs- considered chronic Guillain-Barre Syndrome
166
What are sources of bacterial infection associated with Guillain-Barre Syndrome?
Influenza
Epstein-Barr
Cytomegalovirus
Some vaccines increase the risk
167
What are assessment findings associated with Guillain-Barre Syndrome?
Ascending symmetric muscle weakness, paralysis
Decreased or absent Deep tendon reflexes
Dyspnea, decreased breath sounds, decreased O2, or respiratory failure
Loss of bowel and bladder control
Ataxia
Paresthesia (unpleasant sensation)
Pain or cramping
Facial weakness, dysphagia, Diplopia, difficulty speaking
168
What are nursing interventions for Guillain-Barré syndrome?
Plasmapheresis- remove antibodies causing disease by removing plasma from blood. May need albumin to replace plasma if it doesn't regenerate itself.
If a shunt is used, check it q2-4 hours, keep doubling bulldog clamps at the bedside, and observe for bleeding or ecchymosis
Give IVIG (readily available)- chills, mild fever, HA. Start slow and increase.
Monitor airway- inability to maintain is a high risk.
Monitor ABG and end-tidal CO2.
Low molecular weight heparin (lovenox) and SCDs- Core Measures.
169
What is Myasthenia Gravis?
Myasthenia Gravis is an acquired autoimmune disease characterized by muscle weakness. Slightly higher among men.
Death caused by respiratory failure
Bulbar involvement- affected facial expressions, chewing, and speech
Often associated with Thymoma- encapsulated thymus gland tumor
170
What are some assessment findings associated to myasthenia Gravis?
Most treatable Neurologic disorder.
Ptosis (drooping eyelids), ocular palsies
Diplopia (double vision)
Dysphagia (difficulty chewing/swallowing)
Respiratory compromise, choking, or voice weakness.
Progressive (proximal) muscle weakness, worsens with activity but improves with rest
Poor posture
Loss of Bowel and Bladder control
Fatigue
Muscle achiness
Paresthesia (pins and needles)
Decreased sense of smell and taste
171
What medications can immediately confirm the diagnosis of Mysthenia Gravis?
Cholinesterase Inhibitor drugs (anticholinesterase) First line management for MG. (action: enhance neuromuscular impulse transmission by preventing the decrease of Acetylcholine by the enzyme Cholinesterase)
Drug of choice: Pyridostigmine (Mestinon, Regonol)
AVOID: Mg, MS, sedatives, ABX (neomycin or Tetracyclines)- increase the Myasthenic symptoms
Administer medications with food (45mins-1hr before) and Assess for drug interactions.
172
What are nursing interventions for Mysthenia Gravis?
TENSILON testing (endrophonium chloride) or PROSTIGMIN testing (neostigmine bromide) -- using Cholinesterase inhibitors.
Inject medication- improvement should be noted within 30-60 seconds and lasts 4-5 minutes.
Test may cause cardiac dysrhythmias-- keep ATROPINE SULFATE available (antidote for tensilon)
Tensilon testing can determine if pt is in Cholinergic crisis or Myasthenia crisis.
Cholinergic crisis- too much Cholinesterase inhibitors- Tensilon testing will not improve but WILL cause muscle twitching (fasciculations) around the eyes and face.
Myasthenia crisis- too little Cholinesterase inhibitors
Keep bag-valve mask, oxygen setup and suction equipment at the bedside in case of respiratory distress.
Surgical management: thymectomy (removal of thymus gland)
173
What is a Myasthenic Crisis? And how does it differ from a Cholinergic Crisis?
Myasthenic Crisis: too little Cholinersterase (=overstimulation of nerves/muscles) Caused by infection
Increased HR/RR/BP, Bowel and bladder incontinence, decreased urine output, absence of cough and swallow reflex
IMPROVES with tensilon
Cholinergic Crisis: too much Cholinesterase (= slowing of the nerves/muscles) NO anticholinesterase drug while on mechanical ventilation. give ATROPINE
Flaccid paralysis, thick HYPERsecretions, N/V/D, abd. Cramping, Miosis, blurred vision, pallor
WORSENS with tensilon- eye and face twitching
Maintain AIRWAY/ resp. Functioning
174
How can you improve nutrition for a patient with Myasthenia Gravis?
Assess GAG reflex and chew/swallow
Frequent oral hygiene PRN
Cut food into small bites and eat slowly
Observe for choking and aspiration
Provide High calorie snacks or supplements
Keep the HOB elevated during meals for 30-60 minutes after eating.
Thicken liquids
Monitor calories and food intake
Daily weights
Monitor pre albumin levels
Give Anticholinesterase drugs 45-60 minutes before meals.
175
What patient teaching can be provided for Myasthenia Gravis?
Keep prescribed drug and glass of water at bedside if weak in morning
Wear a watch with an alarm function to remind to take medication
Post drug schedule so others know it
Plan strenuous activities when the drug peaks.
Keep a secure supply of drugs in your car or at work
Check with PCP before using OTCs.
176
What are precipitating factors for worsening Myasthenia Gravis?
Antihistamines, opioids, phenytoin, TCA
```
Rheumatoid Arthritis
Alcohol
Hormone changes
Stress
Infection
Seasonal temp change
Heat, surgery, enemies
```
177
What is a Transient Ischemic Attack? And what are nursing interventions for treating a Transient Ischemic Attack?
TIA is a brief interruption in the cerebral blood flow.
TIA resolves within 30-60 minutes.
Treatment focus is to prevent another TIA or STROKE by decreasing BP, giving ASA/antiplatelet drugs, controlling diabetes, and promoting lifestyle changes.
Core measures- prevent VTE- give antiplatelets, educate pt on precautions and actions to take if bleed occurs.
Reinforce the need for follow-up cares and complete all diagnostic tests.
178
What are assessment findings for a Transient Ischemic Attack (TIA)?
Symptoms resolve within 30-60 minutes.
```
Blurred vision
Diplopia (double vision)
Blindness in one eye
Tunnel vision
Weakness- facial drooping, arm/leg drift, hand grasp
Ataxia (altered gait)
Numbness- face, hands, arm, leg
Vertigo
Aphasia
Dysarthria (slurred speech)
```
179
What is a CerebroVascular Accident (CVA)?
Aka STROKE- caused by an interruption of perfusion to a part of the brain.
MEDICAL EMERGENCY- treat immediately, 3rd leading cause of death.
Brain cannot store Oxygen or glucose- requires constant blood flow to function normally.
180
What are the Different types of ISCHEMIC stroke?
ISCHEMIC stroke: is caused by an occlusion (blockage) of a cerebral artery by a thrombus or embolus.
Thrombolitic stroke: caused by a thrombus (clot), most common. development of atherosclerosis in intracranial or extracranial arteries. Rupture of plagues promote clot formation- interrupting brain tissue (Basilar arteries most common).
Embolic stroke: caused by an embolus (dislodged clot). Usual source is the HEART with Afib.
181
What is a HEMORRHAGIC stroke? And what are the different types?
A HEMORRHAGIC stroke: is caused by interrupted integrity of of brain tissue or subarachnoid space, bleeding occurs.
Intracranial hemorrhage (ICH): bleeding into the BRAIN TISSUE- causing increased BP, leading to edema, distortion, and displacement. Common cause: Cocaine use.
Subarachnoid hemorrhage (SAH): More common- bleeding into the subarachnoid space between the pia mater and the arachnoid layers. Common cause: ruptured aneurysm or arteriovenous malformation.
182
What are assessment findings for a THROMBOTIC stroke?
Improvement between episodes, completed stroke
Gradual onset (minutes to hours)
Awake LOC
Contributing factors: HTN and atherosclerosis
Deficits for the first few weeks- slight HA, speech deficits, visual problems, and confusion
CSF: normal, slight presence of protein
NO seizures
Improvement over weeks to months
183
What are assessment findings for EMBOLIC stroke?
```
Abrupt development of completed stroke, steady progression
Sudden onset
Awake LOC
Contributing factors: Cardiac disease
Maximum deficits at onset, paralysis, and expressive aphasia
CSF: normal
NO seizures
Rapid improvement
```
184
What are assessment findings for a HEMORRHAGIC stroke?
Abrupt onset
Sudden onset, may be gradual if caused by HTN
Deepening stupor or COMA for LOC
Contributing factors: HTN and vessel disorders
Focal deficits, severe and frequent
CSF: bloody
Seizures COMMON
Variable recovery, possible permanent Neurologic deficits
185
What ethnicity has a high prevalence of a stroke?
American Indian or Alaskan Native have the highest prevalence.
Black men and women have more strokes than Caucasian.
Hispanic or Latino men have more strokes than non-Hispanic men.
Excess stroke risk: blacks between 45-65 years account for about half.
186
What are lifestyle factors that can contribute to a stroke should you educate patients on?
Seek healthcare and adhere to recommended treatment plan
Consume a diet high in fruits and vegetables and low in saturated fats.
Light to moderate alcohol may reduce the risk for a stroke, but high consumption may increase it.
187
What are modifiable risk factors that can contribute to a stroke?
```
Smoking
Substance use (Cocaine)
Obesity
Sedentary lifestyle
Oral Contraceptive use
Heavy alcohol use
Use of phenylpropanolamine (PPA) found in antihistamine drugs
```
188
What are common assessment findings for a patient presenting with a stroke?
```
Cognitive:
Aphasia (inability to use or comprehend language)
Alexia or dyslexia (difficulty reading)
Agraphia (difficulty with writing)
Acalculia (difficulty with mathematics)
```
Motor:
Hemiplegia (paralysis of one side of the body)
Hemiparesis (weakness on one side of the body)
Ataxia (gait disturbance)
Hypotonia or flaccid paralysis (cannot overcome force of gravity, extremities fall to the side)
Hypertonia or spastic paralysis (fixed positions or contracture)
189
What are assessment findings for a left hemisphere stroke?
Aphasia, Agraphia, Alexia
| Possible memory loss
190
What are the Different types of ISCHEMIC stroke?
ISCHEMIC stroke: is caused by an occlusion (blockage) of a cerebral artery by a thrombus or embolus.
Thrombolitic stroke: caused by a thrombus (clot), most common. development of atherosclerosis in intracranial or extracranial arteries. Rupture of plagues promote clot formation- interrupting brain tissue (Basilar arteries most common).
Embolic stroke: caused by an embolus (dislodged clot). Usual source is the HEART with Afib.
191
What is a HEMORRHAGIC stroke? And what are the different types?
A HEMORRHAGIC stroke: is caused by interrupted integrity of of brain tissue or subarachnoid space, bleeding occurs.
Intracranial hemorrhage (ICH): bleeding into the BRAIN TISSUE- causing increased BP, leading to edema, distortion, and displacement. Common cause: Cocaine use.
Subarachnoid hemorrhage (SAH): More common- bleeding into the subarachnoid space between the pia mater and the arachnoid layers. Common cause: ruptured aneurysm or arteriovenous malformation.
192
What are assessment findings for a THROMBOTIC stroke?
Improvement between episodes, completed stroke
Gradual onset (minutes to hours)
Awake LOC
Contributing factors: HTN and atherosclerosis
Deficits for the first few weeks- slight HA, speech deficits, visual problems, and confusion
CSF: normal, slight presence of protein
NO seizures
Improvement over weeks to months
193
What are assessment findings for EMBOLIC stroke?
```
Abrupt development of completed stroke, steady progression
Sudden onset
Awake LOC
Contributing factors: Cardiac disease
Maximum deficits at onset, paralysis, and expressive aphasia
CSF: normal
NO seizures
Rapid improvement
```
194
What are assessment findings for a HEMORRHAGIC stroke?
Abrupt onset
Sudden onset, may be gradual if caused by HTN
Deepening stupor or COMA for LOC
Contributing factors: HTN and vessel disorders
Focal deficits, severe and frequent
CSF: bloody
Seizures COMMON
Variable recovery, possible permanent Neurologic deficits
195
What ethnicity has a high prevalence of a stroke?
American Indian or Alaskan Native have the highest prevalence.
Black men and women have more strokes than Caucasian.
Hispanic or Latino men have more strokes than non-Hispanic men.
Excess stroke risk: blacks between 45-65 years account for about half.
196
What are lifestyle factors that can contribute to a stroke should you educate patients on?
Seek healthcare and adhere to recommended treatment plan
Consume a diet high in fruits and vegetables and low in saturated fats.
Light to moderate alcohol may reduce the risk for a stroke, but high consumption may increase it.
197
What are modifiable risk factors that can contribute to a stroke?
```
Smoking
Substance use (Cocaine)
Obesity
Sedentary lifestyle
Oral Contraceptive use
Heavy alcohol use
Use of phenylpropanolamine (PPA) found in antihistamine drugs
```
198
What are common assessment findings for a patient presenting with a stroke?
```
Cognitive:
Aphasia (inability to use or comprehend language)
Alexia or dyslexia (difficulty reading)
Agraphia (difficulty with writing)
Acalculia (difficulty with mathematics)
```
Motor:
Hemiplegia (paralysis of one side of the body)
Hemiparesis (weakness on one side of the body)
Ataxia (gait disturbance)
Hypotonia or flaccid paralysis (cannot overcome force of gravity, extremities fall to the side)
Hypertonia or spastic paralysis (fixed positions or contracture)
Agnosia (unable to use object correctly)
Apraxia (unable to carry out purposeful motor activity or speech)
Emotional Lability (frontal lobe damage) (laughing or crying) (inappropriate emotions to situation)
Increased H&H and WBCs- assess PT and PTT or INR
CT without contrast for INITIAL Dx- after 24 hours will show progressive changes, ischemia, infarction, and cerebral edema.
12 lead EKG: inverted T wave, ST depression, prolonged QT
199
What are assessment findings for a left hemisphere stroke?
Aphasia, Agraphia, Alexia
Possible memory loss
Inability to distinguish words or letters, reading problems, deficit in right Visual field
Slowness, cautiousness, anxiety, depression, sense of guilt, feelings of worthlessness, worried about the future, anger and frustration
No hearing impairment
200
What are assessment findings associated with Right hemisphere strokes?
Impaired sense of humor
Disorientation to person, place, time
Unable to recognize faces
Visual Spatial deficits, neglect of left visual field, loss of depth perception
Impulsiveness, lack of awareness, confabulation, euphoria, constant smiling, denial of illness
Poor judgment, overstimulation of abilities (risk for injury)
Loss of tonal variations
201
What are NANDA nursing diagnoses appropriate for a stroke pt?
```
Inadequate perfusion to the brain
Impaired Swallowing
Impaired physical mobility and self-care deficit
Aphasia or dysarthria
Urinary and/or Bowel Incontinence
Sensory perception deficit
Unilateral neglect
```
202
What interventions would you give to someone how suffered a stroke?
Fibrinolytic drugs- to dissolve the cerebral artery occlusion to re-establish blood flow.
Alteplase (Activase) is the ONLY drug approved for acute ischemic stroke-- it activates plasminogen to degrade the thrombus.
Frequently monitor VS and observe for bleeding.
American Stroke Association recommended to expand the time interval from 3 to 4.5 hours to administer this fibrinolytic unless over the age of 80, INR < 1.7, stroke score > 25, of Hx of stroke/diabetes.
MUST HAVE INFORMED CONSENT
Carotid Artery Angioplasty with Stenting- prevent or manage acute ischemic stroke. Done with moderate sedation in RAD. Go through femoral artery- place stent. TEACH: notify severe HA, change in LOC, muscle weakness, severe neck pain/swelling, hoarseness or dysphagia.
Monitor for ICP within 72 hours of stroke
HOB less than 25 degrees to improve perfusion pressure but HOB greater than 30 degrees can improve O2 and decrease risk of aspiration.
Photophobia- dim lights
Monitor for Hydrocephalus- increased CSF within the ventricular and subarachnoid spaces
ASA for ongoing therapy of ischemic stroke; use Coumadin for pt with Afib.
203
What are nursing interventions during and after IV administration of Alteplase (Activase)?
Double check the dose, use programmable pump, give over 60 minutes but bolus 10% within 1 minute.
Admit to critical care.
Neuro checks and VS q10-15 mins during infusion and q30 mins after for minimum of 6 hours.
-- if systolic pressure greater than 180 or diastolic pressure greater than 105-- give antihypertensives
No invasive tubes until stable
Discontinue infusion if report severe HA, or severe HTN, bleeding, N/V and notify PCP.
Follow up CT scan before giving antiplatelets or anticoagulants.
204
What are interventions to promote effective communication?
Dysarthria is slurred speech (left sided stroke)
| Speech therapy
205
What are the different types of aphasia?
Expressive aphasia: (Broca's) occurs in the frontal lobe- difficulty speaking and writing
Receptive aphasia: (Wernicke's) occurs in the temporoparietal area- difficulty understanding spoken words, written words, speech is meaningless, made-up words.
Mixed aphasia: combination of difficulty understanding and speech, difficulty reading and writing
Global aphasia: profound speech and language problems, often no speech or sounds that cannot be understood.
206
What is a Traumatic Brain Injury? What are common types of TBI?
A Traumatic Brain Injury is damage to the brain from an external mechanical force and not caused by neurodegenerative or cognitive condition.
Direct injury: force produced by a blow to the head
Indirect injury: force applied to another body part with a rebound effect on the brain.
Acceleration injury: external force contracting the head, placing it in motion.
Deceleration injury: moving the head is suddenly stopped or hits a stationary object.
Open traumatic brain injury: occurs when the skull is fractured or when it is pierced by a penetrating object. Linear, depressed, open, or commuted fractures. Most often caused by gun shots and knife injuries. High velocity injuries produce the greatest damage.
Closed traumatic brain injury: the integrity of the skull is not violated. (Blunt force trauma).
- contusion: is a bruising of brain tissue found at the site of impact (coup injury) or a opposite the site of impact (counter coup injury).
- laceration: actual tearing, which may lead to a secondary hemorrhage, significant cerebral edema, and inflammation.
207
What is a Diffuse axonal injury? (DAI)
Occurs when severe brain damage but without local injury such as a contusion or laceration. Usually related to a motor vehicle crash.
208
What is a Mild Traumatic Brain injury? (MTBI)
Aka concussion.
- blow to the head, transient confusion or feeling dazed or disoriented, and loss of consciousness for up to 30 minutes, OR loss of memory for events before and after the event, OR focal Neurologic deficits.
Symptoms usually resolve in 72 hours- persistent symptoms are considered post-concussion syndrome.
75% of all brain injuries.
209
What are common assessment findings for a MIld traumatic Brain injury? (Concussion)
```
Dazed or stunned
Loss of consciousness
HA
N/V
Balance/Gait problems
Dizziness
Visual disturbances
Fatigue
Sensitivity to light and noise
Mentally foggy, slowed down
Difficulty concentrating/remembering
Amnesia
Drowsiness
Sleep less or more than usual or trouble falling asleep
Irritability
Sadness, nervousness, more emotional
```
210
What are nursing interventions or pt education for a mild brain injury?
Neuro check hourly until back to baseline
If HA, give Tylenol q4hr- avoid sedatives for 24 hours
No strenuous activity for 48 hours.
Caution balance and safety concerns
Go to ED if severe HA, persistent vomiting, blurred vision, slurred speech, unequal pupils.
Keep follow-up appointments.
211
What are assessment findings for a brain abcess? And how do you treat it?
Symptoms of a brain abcess include:
HA, fever, pain, motor deficits (hemiplegia), ataxia, sensory impairments, aphasia, seizures, visual field changes
If severe: increased ICP, decreased LOC, severe HA, bradycardia, widened pulse pressure.
Treat with: ABX
