Flashcards in Test 1 Chapter 44 Care of patients with problems of the CNS: The Brain Deck (97):
What are the categories of Migraine Headaches?
The categories of migraines are chronic and unilateral.
Migraines worsen with movement and they occur with photophobia and phonophobia as well as nausea and vomiting. They range from moderate to severe. Place the patient in a dark room.
What is the etiology of a migraine?
Etiology: vascular, genetic, neurologic, hormonal, environmental.
What is the pathophysiology of a Migraine?
Patho: arterial constriction and decrease cerebral flow. Meds can fix this. The brain triggers vessels and they over react, spasm, which triggers a headache.
What are the risk factors for getting a migraine?
women have more than men,
and health problems.
What are the important triggers to remember for a migraine?
Triggers: caffeine, red wine, stress, MSG.
The different types of migraines are:
migraines with an aura,
migraines without an aura,
and atypical migraines.
An aura is a
sensation before it happens that lets them know that it is going to happen.
It is much harder to fix a migraine at the
end stage rather than the beginning stage.
Phases of migraine with aura (classic migraine)
First or Prodromal Phase
- Aura develops over a period of several minutes and last no longer than one hour.
- Well-defined transient focal neurologic dysfunction exist.
- Pain may be preceded by visual disturbances, flashing lights, lines or spots, shimmering or zigzag lights.
- Pain may be preceded by variety of neurologic changes including:
numbness, tingling of the lips or tongue, acute confusional state, aphasia, vertigo, unilateral weakness, drowsiness.
- Headache is accompanied by nausea and vomiting.
- Pain usually begins in the temple. It increases in intensity and becomes throbbing within one hour.
- Pain changes from throbbing to dull.
- Headache, nausea, and vomiting usually last from 4 to 72 hours.
- Older patients may have aura without pain, known as
Atypical migraine - status migrainous
headache lasting longer than 72 hours.
- Neurologic symptoms are not completely reversible within seven days.
- Ischemic infarct is noted on neuroimaging.
- Headache does not fit all of the criteria to be classified as a migraine.
The priority for care of the person having migraines is pain management. This outcome may be achieved by abortive and preventive therapy.
Drugs therapy, trigger management, and complementary and alternative therapies are the major approaches of care.
Provide detailed patient and family education regarding the collaborative plan of care.
Mild migraines may be relieved by
acetaminophen, Abenol, NSAIDS such as ibuprofen, Motrin, and naproxen may also be prescribed
Imitrex is available in tablets, injection, and nasal spray.
This drug is highly effective for pain, nausea, vomiting, and light and sound sensitivity with few side effects.
Imitrex is contraindicated in patients with actual or suspected ischemic heart disease, cerebrovascular ischemia, hypertension, and peripheral vascular disease and in those with Prinzmetal's angina because of the good potential for coronary vasospasm.
Imitrex relieves headache and associated symptoms by
activating the 5 – HT serotonin receptors on the cranial arteries, the basilar artery and the blood vessels of the dura mater your to produce a vasoconstrictive effect.
Imitrex side effects-
dry mouth (can cause cavities), people with heart problems can't take due to coronary artery vasospasms, should not be taken with selective serotonin reuptake inhibitors antidepressants or St. John's wort, and are used commonly for depression.
Nursing safety priority drug alert,
teach patients taking Imitrex to take them as soon as the migraine symptoms develop. Instruct patients to report chest pain or tightness to their health care provider immediately because they may develop angina.
Remind them to use contraception birth control while taking the drug because the drug may not be safe for women who are pregnant.
Teach them to expect common side effects that include flushing, tingling, and hot sensation.
These annoying sensations tend to subside after the patient's body gets used to the drug. Imitrex should not be taken with selective serotonin reuptake inhibitors antidepressants or St. John's wort, and are used commonly for depression
Preventative measures for migraines, beta adrenergic blockers such as
Propranolol and Timolol.
Teach the patient how to monitor their heart rate by checking their radial pulse (not carotid), monitor their blood pressure.
Encourage them to report bradycardia or clinical manifestations of heart failure such as fatigue and shortness of breath to their care provider as soon as possible.
Chart 44-2 things that may trigger a migraine headache
Teach the patients to avoid the foods, medications, and other factors that may trigger a migraine attack.
Food and beverages that contain tyramine:
Alcoholic drinks: beer wine and hard liquor.
Aged cheese, caffeine found in beverages such as coffee, tea, cola. Chocolate. Food with yeast such as pastries and fresh breads. Monosodium glutamate or MSG. Nitrates which are food preservatives, pickled or fermented foods. Nuts. Artificial sweeteners. Smoked fish.
Drugs: cimetidine, estrogen, nitroglycerin, nifedipine.
Other factors: anger, conflict, fatigue, hormonal fluctuations such as menstruation, pregnancy, and menopause. Light glare, missed meals, psychological stress, sleep patterns or problems, smells such as tobacco smoke, Travel to different altitudes.
Complementary or alternative therapies:
exercise, and biofeedback are helpful in preventing or treating migraines for some patients.
Acupuncture may be effective in relieving pain for some patients.
A number of herbs are also used for headaches, both preventative and pain management.
Teach patients that all herbs and nutritional remedy should be approved by their healthcare provider before they use them because they could interact with prescribed medications.
are manifested by brief 30 minutes to two hours, intense unilateral pain that gradually occurs in the spring and fall without warning.
It is classified as the most common chronic short duration headache with pain lasting less than four hours.
Occurs about the same time of day for 1 to 3 months followed by a period of remission.
What is the etiology of a cluster headache?
Etiology: overactive an enlarged hypothalamus.
What are the signs and symptoms of a cluster headache?
Signs and symptoms
ipsilateral( same side) tearing of the eye,
rhinorrhea (stuffy nose or congestion),
pitosis (drooping eyelid),
miosis (constriction of the pupil),
nausea and vomiting,
Assess for possible bradycardia, flushing or pallor of the face, increased intraocular pressure, and increased skin temperature.
Cluster headache interventions,
Drug therapy (similar to migraine) imitrex, Anticonvulsants, calcium channel blockers.
Oxygen via nasal cannula, teach no smoking. (due to decreased blood flow not because of low o2sats.)
Dark rooms, wear sunglasses,
Consistent sleep wake cycle, routine, such as go to bed at the same time get up at the same time.
Avoid precipitating factors such as excitement or burst of anger, anticipation, excess of physical activity.
A seizure is an
abnormal, sudden, excessive, uncontrolled electrical discharge of neurons within the brain that may result in a change in level of consciousness, motor or sensory ability, and or behavior,
What is the etiology of a seizure?
A single seizure may occur for no known reason.
Some seizues are caused by pathologic condition of the brain such as a tumor. It may be caused by an abnormality in the electrical Neuronal activity, and imbalance of neurotransmitters, especially Gama amniobutyric acid or gabba, or combination of both. Can also because by scar tissues within the brain.
Primary: not related to brain lesion or other cause.
Secondary: related to brain lesion caused by brain tumor and trauma. Also related to metabolic disorders, high fever, substance abuse. Cancer can cause seizures as well ,
Epilepsy is defined as
two or more seizures experienced by person. It is a chronic disorder in which repeated unprovoked seizures occur.
The seizures have to be on provoked. So drunk seizures and febrile seizures in children are not epilepsy.
What are the types of seizures?
unclassified idiopathic seizures.
involve both cerebral hemispheres and are referred to as tonic clonic seizures.
The tonic clonic seizure lasting 2 to 5 minutes begins with a tonic phase that causes stiffening or rigidity of the muscles, particularly of the arms and the legs, and immediately immediate loss of consciousness.
Clonic or rhythmic jerking of all extremities follows. The patient may bite his or her tongue and may become incontinent of urine or theses.
Fatigue, acute confusion, and lethargy may last up to an hour after the seizure.
Partial seizures begin in
one part of the cerebral hemisphere and are referred to as focal focal seizures.
They are further subdivided into two main classes: complex partial seizures and simple partial seizures.
In addition, some partial seizures can become generalized tonic clonic, tonic, or clonic seizures.
Partial seizures are most often seen in adults and generally are less responsive to medical treatment when compared with other types.
Unclassified idiopathic seizures
occur for unknown reasons.
are seen with absence seizures, this is involuntary behaviors such as lipsmacking and picking at clothes. He or she is not aware of the behaviors.
The patient returns to baseline immediately after the seizure. Left undiagnosed or untreated the seizure may occur frequently throughout the day, interfering with school or other daily activity.
before the seizure
after the seizure
loss of consciousness
loss of memory
stiffening or rigidity of muscles with an immediate loss of consciousness.
rhythmic jerking of all extremities.
Seizure and epilepsy nursing interventions.
1. Antiepileptic drugs: Dilantin, Klonopin, Depakote, Keppra, Ativan.
2. Prevention, do not stop taking medication, balanced diet and sleep, stress reduction.
nursing interventions monitor for gastric distress, gingival hyperplasia, anemia, ataxia, and nystagmus.
Check CBC and calcium levels, monitor for therapeutic drug levels which are 10 to 20 mcg/mL and toxic levels which are greater than 30 mcg/mL.
Four IV Dilantin, flush catheter was saline before and after administration. For fosphenytoin, use phenytoin equivalent for dosing.
nursing interventions monitor results of liver function tests.
nursing interventions, monitor for hair loss, tremor, increased liver enzymes, bruising, and nausea and vomiting. Monitor CBC, PT, PTT, and AST.
nursing interventions, monitor renal function carefully. Notify healthcare provider for gait or coordination problems.
nursing interventions, monitor airway, breathing, circulation, ABCs. Ativan IM takes 30 minutes to start working, if needed immediately give through the IV.
Check respirations and blood pressure before giving Ativan.
siderails and padding of siderails depends on the hospital,
no padded tongue blades,
bed in the lowest position,
nurses watch closely,
hook up to the monitor,
suction and oxygen ready.
seizure management: protect airway, Ativan through the IV, oxygen, monitor Vital signs, suction.
Nursing safety priority action alert
Seizure precautions include ensuring that oxygen and suctioning equipment with an airway are readily available.
If the patient does not have an IV access, insert a saline lock, especially if he or she is at significant risk for generalized tonic clonic seizures.
The saline lock provides ready access for iv drug therapy that must be given to stop the seizure.
Chart 44 –5 best practice for patient safety and quality care. Care of the patient during a tonic clonic or complete partial seizure.
Protect the patient from injury.
Do not force anything into the patient's mouth.
Turn the patient to the side to keep the airway clear.
Loosen any restrictive clothing the patient is wearing.
Maintain the patients airway and suction as needed.
Do not restrain or try to stop the patient's movement, guide movements as necessary.
Record the time the seizure began and ended.
At the completion of the seizure, take the patient's vital signs, preform neurologic checks, keep the patient on his or her side, allow the patient to rest, document the seizure.
Health teaching for the patient with epilepsy.
Drug therapy information: name, dosage, time of administration. Actions to take if the side effects occur. Importance of taking drug as prescribed and not missing a dose. What to do if the dose is missed or cannot be taken. Importance of having blood drawn for therapeutic or toxic levels as requested by the healthcare provider.
Do not take any medication, including over-the-counter drugs, without asking your healthcare provider.
Where a medical alert bracelet or necklace, or carry an ID card indicating epilepsy.
Follow up with neurologist, physician, or other healthcare provider.
Be sure a family member or significant other knows how to help you in the event of a seizure and knows when your healthcare provider or emergency medical services should be called.
Investigate and follow state laws concerning driving and operating machinery.
Avoid alcohol and excessive fatigue.
Look for resources and support groups.
A seizure lasting more than five minutes or a seizure repeating over the course of 30 minutes.
Seizures lasting more than 10 minutes can cause death.
Etiology, sudden withdrawal of antiepileptic drugs, infection, EtOH withdraw (alcohol), head trauma, cerebral edema, metabolic disturbance, infection, severely wasted, throwing up, falls like off a roof.
Nursing interventions for status elipepticus, give Ativan IV push until the seizure stops then hang Dilantin trip. Monitor respirations and blood pressure. And follow all seizure precautions.
inflammation of the meninges that surround the brain and spinal cord.
Etiology, bacterial or viral.
Risk factors, otitis media, pneumonia, acute or chronic sinusitis, sickle cell anemia, brain or spinal surgery.
Pathophysiology of meningitis,
organism enters the central nervous system via the bloodstream and at the blood brain barrier causing inflammation and exudate and increased intracranial pressure. Causes pus and pressure on everything.
self-limiting with complete recovery.
life-threatening causes loss of limbs and loss of mental functioning. With bacterial meningitis people usually die.
Meningococcal meningitis is the most common bacterial meningitis.
Emergency with high mortality rate, causes the most severe presentation.
It affects the meninges, subarachnoid space, and brain tissue.
It is highly contagious.
It occurs in outbreaks in areas of high population and density areas. Such as in college dorms, day cares, and very crowded places. People get very very sick.
Meningitis clinical manifestations,
fever, headache, altered mental status, photophobia, nuchal rigidity.
Meningitis nursing interventions,
laboratory, draw blood
Nursing assessment including neuro checks
Standard precautions with dropplet precautions for bacterial. If the patient has this, they have to have a mask when being transported outside of the room.
Lumbar puncture: analysis of cerebrospinal fluid if – cerebrospinal fluid is clear, this means no infection. If the cerebrospinal fluid is white or cloudy that's usually a sign of meningitis.
Nursing safety priority action alert
Place the patient with bacterial meningitis that is transmitted by droplets on droplet precautions in addition to standard precautions.
When possible, place the patient in a private room.
Stay at least 3 feet from the patient and less wearing a mask.
Patients who are transported outside of the room should wear a mask and follow respiratory hygiene such as coughing etiquette.
Teach visitors about the need for these precautions and how to follow them.
In cloudy cerebrospinal fluid
the WBC, protein will be increased and the glucose will be decreased. Pressure increases. (bacterial)
In clear cerebral finals spinal fluid
the white blood cells, protein will be increased glucose will being decreased or normal and cerebrospinal pressure varies. Usually seen with viral.
A lumbar puncture is used to diagnose meningitis.
While doing a lumbar puncture you need to position the patient in the fetal position with access to the back.
Need to medicate if lethargic. Set up the supplies, CSF is drawn in numerical order, the first vile is considered contaminated.
must draw four vials, must label at the bedside, after the lumbar puncture the patient must remain flat to avoid headache.
It is the nurses job to label and walk to the lab cannot be put on ice and cannot be sent through the tubes to the lab.
Spinal headaches can occur after a lumbar puncture.
Require the patient to lay flat for and one hour. CSF Can still leak out but it Resolves on its own usually. Can give a blood patch if last to long.
Care of the patient with meningitis
Follow the ABC's
Take vital signs and preform neurologic checks every 2 to 4 hours as required
Preform cranial nerve assessments with particular attention to cranial nerves 3, 4, 6, 7 and 8 and monitor for changes.
Manage pain with drug and nondrug methods.
Preformed vascular assessment and monitor for changes.
Give drugs and IV fluids as prescribed, and document the patient's response.
Record intake and output carefully to maintain fluid balance and prevent fluid overload.
Monitor bodyweight to identify fluid retaining early.
Monitor laboratory values closely, reporting abnormal findings to the physician or nurse practitioner promptly.
Position carefully to prevent pressure ulcers.
Preform range of motion exercises every four hours as needed.
Decrease invite environmental stimuli by providing a quiet environment, minimizing exposure to bright lights from windows and overhead lights, maintain bed rest with head of the bed elevated to 30°.
Maintain transmission based precautions per hospital policy for bacterial meningitis.
Monitor for and prevent complications such as increased intracranial pressure, vascular dysfunction, fluid and electrolyte imbalance, seizures, shock.
inflammation of the brain tissues and offing the surrounding meninges. (It is not all of the meninges just the surrounding ones.)
Infection travels to the central nervous system be in the bloodstream, along the peripheral or cranial nerves or in the meninges.
Affects the cerebrum, brainstem, and cerebellum.
Demyelination of axons occur, leads to hemorrhage, edema, necrosis within the cerebral hemispheres.It also causes an increase in intracranial pressure.
Etiology of Encephalitis,
virus, bacteria, or fungi. can be caused by a mosquito bites or chickenpox virus.
It is related to arboroviruses, West Nile virus, and enteroviruses.
Nursing interventions for encephalitis,
teach people who live in mosquito infested areas to protect themselves and their families from West Nile virus infections. There is also no curative treatment for West Nile viral encephalitis.
Limit your time outside between dusk and dawn when mosquitoes are out.
Where protective clothing, including long sleeves and pants.
Use an insect repellent containing Ditte when outdoors.
Remove areas of standing water from flowerpots, trash cans, and rain gutters. Check window and door screens for holes that need to be repaired.
Keep hot tubs and pulls clean and properly chlorinated.
Clinical manifestations of encephalitis,
fever, nausea, vomiting, nuchal rigidity, motor weakness.
Nursing interventions for encephalitis,
Lumbar puncture, clear or cloudy, take to the lab
Education, do not tell them about bug spray if they're already infected,
Nursing assessment including neuro assessments
Some may have permanent neurologic deficits. Discharge to home or to rehab.
Parkinson's disease, progressive neurodegenerative disease.
***Characterized by four signs and symptoms tremor, rigidity, bradykinesia or akinesia, and posterior instability.
Parkinson's disease etiology
environmental, genetic factors.
Risk factors include exposure to pesticides, greater than 40 years old, reduced estrogen levels, men have a greater chance of getting it than women.
-dopamine produced in the gray matter of the brain, produce nerve cells transmitted to the brain when needed.
-Acetylcholine produced by neurons, make things excitable. Gets things moving.
When dopamine is released it lets your body have more control over the acetylcholine.
Sympathetic nervous system decreases with Parkinson's disease.
Slows the heart rate and the blood pressure. Orthostatic hypotension puts elderly patients at fall risks.
Fall risks are greater at night in the elderly. Educate them to sit on the corner of their bed for a couple of minutes before standing.
Clinical manifestations of Parkinson's disease,
dopamine decreases in the brain, person loses refined motor skills.
Stages of Parkinson's table 44-3
Stage 1 : initial stage, unilateral limit involvement, minimal weakness, hand and arm trembling.
Stage 2: mild stage, bilateral limb involvement, mask like face, slow shuffling gait.
Stage 3: moderate disease, postural instability, increased gait disturbances.
Stage 4: severe disability, alkinesia, rigidity.
Stage 5: complete ADL dependence .
Key features of Parkinson's disease:
Posture: stooped posture, flexed trunk, fingers abducted and flexed, wrist slightly dorsiflexed.
Gait: slow and shuffling, short hesitant steps, propulsive gait, difficulty stopping quickly.
Motor: bradykinesia slow movement, muscular rigidity, alkinesia, tremors, Pill rolling movement, masked like face, difficulty chewing and swallowing, uncontrolled drooling, fatigue, difficulty getting in and out of bed, reduced arm swinging on one side of the body when walking, micrographia (change in handwriting or handwriting gets smaller.)
Speech: soft low pitch voice, slurred speech, echolalia, hypophonia (soft voice),
Autonomic dysfunction: orthostatic hypotension, excessive perspiration, oily skin, seborrhea , Flushing, changes in skin texture, eyelid spasms,
Psychosocial assessment: emotional labile, depressed, paranoid, easily upset, rapid mood swings, cognitive impairments such as dementia, delayed reaction time, sleep disturbances.
Nursing interventions for Parkinson's disease
Drug therapy- requip dopamine agonists last about 5 years.
Parkinson's patients do not sleep well, it is important that for them to exercise.
Nursing safety priority drug alert
Dopamine agonist are associated with adverse effects such as orthostatic hypotension, hallucinations, sleepiness, and drowsiness.
Remind patients to avoid operating having machinery or driving if they have any of these symptoms.
Teach them to change from a lying or sitting position to a standing by moving slowly.
The healthcare provider should not prescribe drugs in this class to older adults because of their severe adverse drug effects.
When drug tolerance is reached, the drugs affect do not last as long as previously.
The treatment of Parkinson's disease drug toxicity or tolerance includes: a reduction in the drug dose, a change of drug or in the frequency of administration, or a drug holiday particularly with levodopa therapy.
During a drug holiday, which typically lasts for up to 10 days, the patient receives no drug therapy for Parkinson's disease.
Carefully monitor the patients for symptoms of Parkinson's disease during this time, and document any assessment findings.
loss of memory, loss of judgment, Vizio spatial perception, changes in personality, cognitive impaired, physical deterioration.
Alzheimer's disease, dementia, vascular degeneration, abnormalities in the neurotransmitters,
Etiology of Alzheimer's disease :
age, gender female, family history.
Stages, early mild or stage one, first symptoms up to four years.
Independent and ADLs, no special social or employment problems initially,
denies presence of symptoms,
misplaces household items,
short-term memory loss,
difficulty recalling new information,
settle changes in personality and behavior,
loss of an initiative,
less engaged in social relationships,
mild cognitive impairment,
problems with judgment,
especially when stressed,
unable to travel alone to new destinations, decreased sense of smell.
Middle, moderate, or stage II. 2 to 3 years.
Impairment of all cognitive functions,
problem with handling or unable to handle money and finances,
disorientation to time,
place, an event.,
Possible depression or agitation,
increasingly dependent in ADLs,
visuospatial deficits such as difficulty driving and getting lost,
speech and language deficits such as less talkative,
decreasing use of vocabulary,
and eventually aphasia. In continent, wandering and trouble sleeping.
Late, severe, or stage III.
Completely incapacitated and bedridden,
totally dependent in ADLs,
motor and verbal skills lost, general and focal neurologic deficits,
loss of facial recognition.
Pathophysiology of Alzheimer's disease,
also known as dementia, Alzheimer's is a chronic progressive, degenerative disease that accounts for 60% of the dementias occurring and people older than 65 years old.
inability to use words or objects correctly
inability or difficulty to speak or to understand.
loss of sensory comprehension.
increased confusion at night.
Inability to recognize oneself and other familiar faces
difficulty finding words to name an object.
Nursing interventions for Alzheimer's disease
Drug therapy, Aricept, Zoloft, Halidol, Ativan PRN.
Psychosocial therapy, interventions, needs stable environment, don't like change.
Safety, these patients do not sleep well, do not wake them up if they are sleeping, take them on frequent walks while awake during the day. Restraints increased agitation as well as loud noises like music or TV please try to avoid these things
Dementia, give meds to help, make sure family knows that it is not going to cure it.
Illnesses, such as UTI will cause mental status changes. Please monitor for these carefully.
For Alzheimer's patients use direct and simple questions.
Use validation therapy. Invalidation therapy, the staff member recognizes and it knowledges the patients feelings and concerns.
For example, if the patient is looking for a deceased mother, ask him to talk about what mother looks like and what she might be wearing.
This response does not argue with the patient but does not reinforce the patients believe that the mother is still living.
hereditary disorder transmitted as and autosomal dominant trait at the same time of conception.
Neurologic and behavioral symptoms and signs and symptoms begin between 30 years and 50 years, then worsen in the next 1 to 2 decades.
Clinical manifestations of Huntington's disease,
progressive mental status changes leading to dementia, Choreiform movements, disease progresses in stages.
Huntington's disease is hereditary and you only get it if you have that gene. It consists of quick abnormal involuntary movements and is diagnosed by having a family member who has it, chorea movements, and dementia.