Neurologic Trauma 8-10 Questions

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Neurologic Trauma8-10 Questions

• Monti Smith, MSN, RN

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Increased Intracranial Pressure

• The cranial vault contains
• Brain tissue
• Blood
• Cerebrospinal fluid
• These three things give your brain a state of
  equilibrium
• Monro-Kellie Hypothesis - ? in any of the cranial
  vault components causes a change in the volume of
  the others by displacing or shifting CSF, ? CSF
  absorption or ? blood volume

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Pathophysiology of ICP

• Normal ICP is 10 15 mm Hg
• Most commonly associated with head injury
• Secondary effect in conditions such as
• Brain tumor
• Subarachnoid hemorrhage
• Encephalopathies
• ? ICP affects cerebral perfusion, produces
  distortion, and shifts brain tissue

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Pathophysiology cont.

• Reduced cerebral blood flow results in ischemia
• Complete ischemia for gt 3-5 mins. results in
  irreversible damage
• Early stages of ischemia - vasomotor centers are
  stimulated resulting in a slow bounding pulse
  respiratory irregularities

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Pathophysiology cont.

• CO2 concentration regulates cerebral blood flow
  rise causes dilation whereas a fall
  vasoconstricts
• Cerebral edema occurs when there is ? in water
  content of the brain tissue

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Pathophysiology Cerebral Response to ? ICP

• Autoregulation the brains ability to change
  the diameter of its blood vessels automatically
  for maintenance of constant cerebral blood flow
• Cushings response the brains attempt to
  restore blood flow by increasing arterial
  pressure to overcome increased intracranial
  pressure

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Decompensation Phase

• Exhibit changes in mental status V/S
  Cushings triad
• Bradycardia
• Widening pulse pressure/hypertension
• Respiratory changes
• Herniation of brain stem occlusion of cerebral
  blood flow cerebral ischemia infarction
  leading to brain death

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If there is a Q on the test

• What you would look for in the question, do they
  have these three things
• Far apart BP
• Pulse in the 50s
• Temp would be high

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Clinical Manifestations of ?ICP

• Change in level of responsiveness-consciousness
• The most important indicator of the pts
  condition
• Any sudden change in condition has neurologic
  significance
• Restlessness without cause
• Confusion
• ? drowsiness

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Complications of ?ICP

• Brain stem herniation
• Not much you can do for this
• Diabetes insipidus
• Treat with fluid, check on lytes
• Syndrome of inappropriate antidiuretic hormone
• Restrict fluids

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Management of ?ICP

• ?ICP is a true emergency a treat promptly
• Goal ? cerebral edema, lowering volume of CSF,
  or ? blood volume while maintaining cerebral
  perfusion
• Administer osmotic diuretics to dehydrate brain
  reduce cerebral edema
• Mannitol
• Glycerol

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Nursing Diagnoses

• Ineffective airway clearance
• Diminished cough and gag reflexes
• Ineffective breathing patterns
• Ineffective cerebral tissue perfusion
• Deficient fluid volume
• Risk for infection
• b/c of hole they put in head to monitor pressure

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What Can The Nurse Do?

• Maintain airway monitor breathing
• Maintain proper positioning
• Maintain proper fluid balance
• Monitor for s/s of infection
• Monitor for potential complications
• Stool softeners to prevent straining during a poo
• Keep an emotional/stress free environment

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Management of ?ICP

• Foley catheter to monitor urinary output
• Serum osmolality levels to assess hydration
• Corticosteriods to help reduce edema
• Maintain cerebral perfusion by using fluid volume
  inotropic agents
• Reduce CSF blood volume by draining CSF
• Control fever to ? rate at which cerebral edema
  forms

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Head Injuries

• Trauma to scalp, skull, or brain
• Primary initial damage to the brain (like you
  get hit in the head with a hammer)
• Secondary evolves over hours days after the
  injury (like Liam Neesons wife)
• An injured brain is different than other injured
  body parts because of its location!
• There is no where for the swelling and all that
  to go, so the pressure just increases and is
  super bad news
• Scalp injuries causes lots of bleeding, but
  usually minor

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Types of Force

• Acceleration injury
• Head in motion
• Like in a car wreck
• Deceleration injury
• Head suddenly stopped
• Like if youre sitting stopped in your car and
  someone hits you

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Skull Fractures

• Break in the continuity of the skull caused by a
  forceful trauma
• Fracture may be open or closed
• Open is if you have any tear in the dura
• Closed is when the dura is still intact
• Types of Fractures
• Simple a clean break, straight little line
• Comminuted a splintered break or there are
  multiple fracture lines
• Depressed bone fragments that are depressed or
  imbedded into the brain tissue
• Basilar fracture at the base of the skull

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Clinical Manifestations

• Dependent on severity and distribution of brain
  injury
• Persistent, localized pain suggest fracture
• X-ray needed for diagnosis
• Basilar skull fracture frequently produces
  hemorrhage and CSF leakage
• Bloody CSF suggests brain laceration or contusion

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Assessment Diagnostics

• Physical Exam Neuro status
• CT scan
• MRI
• Cerebral angiography

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Medical Management

• Close observation if nonsurgical
• HOB is usually 30 degrees
• Surgery for depressed fractures
• IV antibiotics for these guys
• Monitor for CSF leakage
• Might leak out ears (otorrhea) and nose
  (rhinorrhea)
• Get some sterile gauze and place it with some
  tape under their nose. Tell the pt not to be
  blowing their nose

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Traumatic Brain Injury

• Occurs as a result of an external physical force
  that may produce a diminished or altered state of
  consciousness
• The brain responds to forces by forward movement
  within the cranial vault
• Motor vehicle crashes are the most common cause
• The cognitive impairment that they suffer from
  that is usually irreversible

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Battle Sign

• Like a bruise or whatever behind their ear. This
  is a good indicator that they hada basilar skull
  fracture. This is a good assessment.

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Primary Brain Injury

• Results from physical stress within the brain
  tissue caused by open or closed trauma
• Open head injury occurs with skull fracture or
  penetration of the skull
• The brain has been exposed to the
  outside/environmental contaminants. Not too good
  Damage that occurs to the vessels, sinuses,
  cranial nerves, anything like that
• Closed head injury result of blunt trauma and
  is more serious
• Youre hit really hard and your brain gets
  squished. You cant really go in and repair
  anything.

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Types of Brain Injuries

• Concussion minor, client may or may not lose
  consciousness, causes no structural damage
• These guys should go to the hospital to make sure
  its not something more serious, but generally
  these people will be sent home and be given
  instructions to stay awake or woken often if they
  do sleep. Make sure theyre not confused,
  vomiting, c/o weakness or HA, etc. This is
  important b/c these are signs of internal damage.
  Usually take a few days to get over
• Contusion major, client loses consciousness,
  brain is bruised
• This pt may lose consciousness for a few mins,
  usually have a decrease in BP, respirations, can
  lose control of their bowel/bladder. Usually when
  they go unconscious you can usually easily rouse
  them, but theyre very hyperactive when they get
  up (like all jumpy and what-not). Usually take
  several months to get over. Client may be left
  with HA, vertigo, seizures after the contusion.

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Epidural Hematoma

• Results from arterial bleeding into the space
  between the dura and inner surface of the skull.
• Often these are caused by fractures of the
  temporal bones. The break can cause a tear to the
  artery right there and it will form quickly

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Epidural Hematomas

• Initial s/s
• They go unconscious then they have a brief period
  of lucidity followed by a decreased LOC
• This is a medical emergency! This person can have
  respiratory arrest w/I minutes!
• For this person they go in and drill holes to
  decrease the ICP. If theres a clot they go in
  and remove it. If there is a bleed theyll go and
  try to stop it. Might put in a drain to prevent
  reacumulation of the blood

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Medical Management

• MEDICAL EMERGENCY!!!!!
• Burr holes through skull
• Possible craniotomy
• Drain

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Subdural Hematoma

• Results from venous bleeding into the space
  beneath the dura and above the arachnoid
• Most common cause is trauma. Can be caused by
  bleeding disorderes or ruptured aneurysms. Most
  are venous (caused by ruptures of small vessels).
  Arterial ones are more rapid.

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Types of Subdurals

• Acute occur with major head trauma, s/s develop
  over 24-48 hours.
• S/S changes in LOC
• Subacute occur with less severe contusions, s/s
  develop 48 hours-2 weeks
• S/S changes in LOC
• Chronic occur with minor head injuries, s/s
  develop 3 weeks-3 months, most frequently seen in
  the elderly (we get older and our brain shrinks
  in our skull that stays the same size). Harder to
  diagnose. Symptoms can mimic dementia or
  Alzheimer's

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Intracerebral Hemorrhage

• Accumulation of blood within the brain tissue
  caused by tearing of small arteries and veins in
  the white matter
• Direct trauma (fractures and things, bullet
  wounds, stab injuries). Youll see it a lot if
  someone has a tumor that bleeds all around it.
  High BP can cause this, anti-coagulation therapy
  people who fall and hit their heads, bleeding
  disorders

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Medical Management of Brain Injuries

• Physical neurological exam
• CT MRI scans
• Ventilatory support
• Seizure prevention
• Fluid electrolyte maintenance
• Nutritional support
• Management of pain anxiety

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What Is The Nurses Responsibilities?

• Ongoing neurological assessment
• LOC
• VS
• Motor function
• Pupil size

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Cerebrovascular Disorders(6-8 Questions)

• Monti Smith, MSN, RN

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Stroke

• Definition A disruption in the normal blood
  supply to the brain
• Medical emergency. Needs to be treated
  immediately, the longer it lasts the worse the
  symptoms are
• 3rd most common cause of death in the United
  States
• Primary cause of adult disability in the United
  States

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Types of Strokes

• Ischemic
• Thrombotic
• Embolic
• Transient Ischemic Attack
• Hemorrhagic

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Thrombotic Stroke

• Results from thrombosis or narrowing of a blood
  vessel
• Most common cause of strokes
• Associated with DM HTN
• Can be preceded by a TIA
• Usually dont lose consciousness in the first 24
  hours

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Embolic Stroke

• Embolus dislodges occludes a cerebral artery
  resulting in infarction edema
• Second most common cause of stroke
• Mostly originates from the endocardial layer of
  the heart
• Lodges wherever the vessel narrows or where it
  bifurcates
• If we dont treat the underlying cause of these
  kinds of strokes or else it is almost certainly
  going to happen again

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Hemorrhagic Stroke

• Caused by bleeding into the brain tissue,
  ventricles, or subarachnoid space
• Causes can vary
• HTN, aneurysms, bleeding tumors
• You dont want these kinds of strokes. If you
  survive the acute phase youre going to have
  major problems
• Deficits are severe recovery is long

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Transient Ischemic Attack (TIA)

• Temporary loss of neurologic function caused by
  ischemia
• Can last from 15 minutes to 24 hours
• Serve as a warning sign of further
  cerebrovascular disease
• Complete recovery between attacks

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Clinical Manifestations

• Motor deficits
• Hemiparesis
• Hemiplegia
• Ataxia
• Communication
• Dysarthria
• Dysphagia
• Aphasia
• Expressive Aphasia their brain is thinking
  correctly but the words are coming out wrong.
  They know what they want to say but cant get it
  out
• Receptive Aphasia they get confused by what you
  say. On the way from the ear to the brain the msg
  gets messed up. It never gets

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Clinical Manifestations cont.

• Cognitive Impairment
• Memory loss
• ? attention span
• Poor reasoning
• Altered judgment
• Psychological Effects
• Loss of self-control
• Depression
• Emotional lability

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Clinical Manifestations cont.

• Perceptual Disturbances
• Homonymous hemianopsia
• Loss of half of your visual field
• Loss of peripheral vision
• Diplopia
• Difficulty judging distances
• Apraxia
• Inability to perform a previously learned action

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Assessment Diagnostic Findings

• History, assessment, neuro exam
• CT without contrast
• EKG
• Carotid doppler
• May also see
• Cerebral angiogram
• Transcranial doppler
• Transesophageal echocardiography
• Put scope down throat to look at the back of your
  heart. A regular echo cant see the back of the
  heart.
• MRI

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Medical Management for Acute Stroke

• Thrombolytic Therapy within 3 hours of s/s
• Noncontrast CT of head
• Looking for blood. If they have blood it means it
  might be a hemorrhagic stroke and you dont want
  to give them things that are going to increase
  their risk of bleeding
• Blood tests for coagulation studies
• Screening for hx of GI bleeding in past 3 months
  or major surgery in last 14 days

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Surgical Management

• Carotid endarterectomy
• Go in and clean out the carotid arteries of
  plaque and stuff
• Carotid stenting
• Dont see this alone as much. May do the cleaning
  and stenting at the same time
• Aneurysm clipping, coiling
• Resection of arteriovenous malformation (AVM)

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Medical Management

• Prevention is the most important!
• What are some modifiable risk factors?
• HTN
• Afib
• ? Lipids
• DM
• Smoking
• Carotid stenosis
• Obesity
• Excessive alcohol consumption

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Medical Management

• Coumadin for atrial fibrillation
• Plavix, ASA, Ticlid for TIAs and strokes from
  suspected embolic or thrombotic causes
• Statins
• For cholesterol
• Antihypertensives

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Acute Nursing Interventions

• Support respiratory system
• Frequent neuro exam
• Monitor cardiovascular system
• Monitor musculoskeletal system
• Monitor for skin breakdown
• Monitor for constipation
• Promote normal bladder function
• Right after theyve had the stroke be super nice
  to them
• Then in rehab we are harder on them. Boot camp
  kind of thing.

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Acute Nursing Interventions cont.

• Assess monitor nutritional status
• Be supportive with communication efforts
• Initially arrange clients environment within
  their perceptual field
• Use their good eye, so to speak
• Give client family clear understandable
  explanations regarding situation and procedures

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Nursing Diagnoses for Patients with Stroke

• Impaired physical mobility R/T hemiparesis, loss
  of balance and coordination, spasticity, and
  brain injury
• Acute pain (shoulder) R/T hemiplegia and disuse
• Self-care deficits R/T stroke sequelae
• Disturbed sensory perception R/T altered sensory
  reception, transmission
• Impaired swallowing

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Nursing Diagnoses

• Incontinence R/T flaccid bladder, detrusor
  instability, confusion, or difficulty
  communicating
• Disturbed thought processes R/T brain damage,
  confusion, or inability to follow instructions
• Impaired verbal communication R/T brain damage

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Nursing Diagnoses

• Risk for impaired skin integrity R/T
  hemiparesis/hemiplegia, or ? mobility
• Interrupted family processes R/T catastrophic
  illness and caregiving burdens
• Sexual dysfunction R/T neurologic deficits or
  fear of failure

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Goals for Patient Family

• Improvement of mobility
• Avoidance of shoulder pain
• Achievement of self-care
• Attainment of bladder control
• Improvement of thought processes
• Achievement of some form of communication
• Maintenance of skin integrity
• Restoration of family functioning
• Absence of complications

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Achieve Self-Care

• Encourage to assist in personal hygiene as soon
  as able to sit up
• Start with affected side
• Dressing - better balance in seated position
• Improves morale if fully dressed
• Use clothing size larger than normal
• Place on affected side - dress first

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Attain Bladder Control

• Offer urinal/Bedpan on schedule
• Upright posture standing position for males

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Achieve Communication

• Speech-language therapist to assess needs
• Be sensitive to reactions needs
• Always treat patient like an adult
• Lend strong moral support
• Consistent schedule, routines, repetition
• Surround with familiar objects
• Have attention, speak slowly, one at a time

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Maintain Skin Integrity

• Emphasis on bony areas dependent parts
• Specialty bed during acute phase
• Regular turning positioning schedule
• Keep skin clean dry
• Gentle massage of healthy skin
• Adequate nutrition

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Improve Family Coping

• Family plays important role in recovery
• Involve them in patients care
• Need to avoid doing for patient what patient can
  do for himself
• Inform them rehab is long progress may be slow

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Sexual Dysfunction

• Profoundly altered by disability
• Often experience loss of self esteem value
• Encourage to keep active, adhere to exercise
  program, continue to remain self sufficient
• May benefit from sexual counseling

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Home Care Planning

• May require speech therapist occupational
  therapist
• Emotionally
• tires easily
• will become irritable upset at small things
• likely to show less interest in things
• depression is common

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Home Modification

• OT assess home environment recommends
  modifications
• Shower - sitting on stool
• Long-handled bath brush
• Portable shower hose
• Handrails

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Communication

• Speech-language pathologist assess ability to
  communicate
• Nursing - includes listening, asking to follow
  simple directions, observing cope with
  dysfunction

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Continued Management

• Promoting positive self-esteem
• Give as much psychological security as possible
• Patience understanding while learning to speak
• Treat patient as adult - use kind, unhurried
  manner
• Accept patients behavior feelings
• Avoid completing thoughts sentences for patient
• Environment should be relaxed permissive
• Encourage to socialize with family/friends

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Critical Thinking

• The nurse planning care for a client who suffered
  a cerebrovascular accident (CVA) with residual
  dysphagia would write on the care plan to avoid
  doing which of the following during meals?
• (A) Feed the client slowly
• (B) Give the client thin liquids
• (C) Give foods with the consistency of oatmeal
• (D) Place food on the unaffected side of the mouth

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Brain Tumors

• Definition A localized intracranial lesion that
  occupies space within the skull.
• Tumors usually grow as a spherical mass but can
  grow diffusely, infiltrating tissue.

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Brain Tumors

• Primary
• Originate within the CNS
• Cause unknown possibly genetics, defective
  immune system, heredity, viruses, head injury
• Secondary/Metastatic
• Develop from structures outside the brain
• Lesions occur commonly from lung, breast, lower
  GI, pancreas, kidney, skin

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Gliomas

• Most common brain neoplasm about 60 of all
  brain tumors
• Spread by infiltrating into surrounding neural
  tissue
• Total removal causes considerable damage to vital
  structures
• Astrocytomas most common type

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Pituitary Tumor

• Most common is Adenoma
• 10 25 of all brain tumors
• Symptoms are caused by pressure on adjacent
  structures or hormonal changes
• Pituitary gland AKA hypophysis

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Menigioma

• Encapsulated, globular, and well demarcated
• Causes compression and displacement of
  surrounding brain tissue
• Tends to recur

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Acoustic Neuroma

• AKA cerebellar pontine angle tumors because of
  anatomic location.
• On the 8th cranial nerve
• More prevalent in females
• Common symptoms hearing loss, tinnitus, and
  dizziness

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Clinical Manifestations of Brain Tumors

• Symptoms of increased ICP
• Headache
• Vomiting
• Papilledema
• Personality changes
• Focal deficits
• Motor
• Sensory
• Cranial nerve dysfunctions

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Diagnostic Findings

• CT Scan, MRI, PET Scan
• Stereotactic biopsy diagnoses deep-seated brain
  tumors
• Cerebral Angiography for visualization of
  cerebral blood vessels
• Because sometimes tumors are very vascular and
  they dont want to cut it out before they get rid
  of the vessels cause you might bleed to death
• EEG Detects abnormal brain waves and temporal
  lobe seizures
• Cytologic studies of CSF detect malignant cells

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Treatment Modalities

• Transsphenoidal microsurgical removal
• Up your nose. Take the tumor out of your nose!
  Eww
• Radiosurgery with a Gamma Knife delivers high
  dose of radiation no surgical incision
• Stereotactic Laser or radiation delivery
  Implantation of radioisotopes
• External-beam radiation
• Brachytherapy surgical implantation of
  radiation sources

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Nursing Management

• Monitor patient for aspiration (surgical)
• Monitor for ?ICP
• Frequent reorientation may be required
• Monitor patients with seizure history
• Assess motor function
• Assess speech
• Pupillary size and reaction may be affected by
  cranial nerve involvement

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Cerebral Metastases

• Metastatic brain lesions constitute 10 of all
  intracranial tumors
• Cerebral Metastases is most common
• Signs and Symptoms include

• Headache
• Paralysis
• Seizures
• Aphasia

• Focal Weakness
• Altered Mentation
• Personality Changes

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Medical Management

• Palliative treatment
• Surgery
• Treatment of choice for brain tumors
• Radiation therapy
• Chemotherapy
• Corticosteroids headaches (to decrease chance
  of HA)
• Osmotic agents decrease IOP (i.e. manitol)
• Anticonvulsants
• Analgesics
• You probably wont see chemotherapy IV because
  chemotherapy cant cross the BBB

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Seizures Headaches(8-10 Questions)

• Monti Smith, MSN, RN

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Seizure Disorders

• Definition An abnormal, sudden, excessive
  discharge of electrical activity within the brain
• Causes vary and are classified as
• Primary/Idiopathic no identifiable cause
• Secondary hypoxemia, fever, head injury,
  hypertension, CNS infections, metabolic/toxic
  conditions, brain tumor, drug withdrawal,
  allergies

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Seizures

• Six types of generalized seizures
• Tonic-clonic
• Generalized seizures, also called Grand Mauls or
  whatever. 2-5 minutes, person goes rigid, LOC,
  incontinence. After they come around theyre
  confused and all that mess
• Absence
• They just stare off, usually last seconds
• Myoclonic
• Brief jerking or stiffening of the extremities.
  Usually last for a few seconds.
• Atonic/Akinetic
• Lost of muscle tone, may fall down.
• Clonic
• Tonic

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Seizures

• Partial or Focal
• Two main classes
• Complex
• Psychomotor
• Temporal lobe seizures
• Simple

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Seizures

• Unclassified/Idiopathic
• Account for about half of all seizure activity
• Occur for no known reason
• Do not fit generalized or partial classification

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Seizures

• Patient may have memory loss during seizure
  activity a short time thereafter
• Brain damage may occur when seizures are severe
  or prolonged
• Risk for hypoxia, vomiting, pulmonary aspiration,
  persistent metabolic abnormalities
• Goal of treatment is control of the seizure and
  determination and control of the cause long-term
• If we can figure out whats causing it and treat
  that then we have a good chance of getting rid of
  these guys

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Management

• Management meets individual patient needs not
  just manage and prevent seizures
• Drug therapy goal is to achieve seizure control
  with minimal side effects
• Drug therapy controls rather than cures

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Status Epilepticus

• Definition Acute prolonged seizure activity
• Either last 30 mins or seizure after seizure
  after seizure after seizure after seizure and so
  on
• The brain isnt getting any oxygen during this
  time
• Considered a major medical emergency
• Produces cumulative effects
• Repeated episodes of cerebral anoxia swelling
  may lead to irreversible fatal brain damage
• Goal of management is to stop the seizures as
  quickly as possible, ensure adequate cerebral
  oxygenation, and maintain a seizure-free state

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Seizure Treatment

• Vagal Nerve Stimulation (VNS)
• Controls medically intractable simple or complex
  partial seizures
• Appropriate for persons not candidates for
  surgical intervention
• Appropriate for persons not controlled by less
  invasive treatment options
• Surgically implanted in the left chest wall
• Activated to deliver intermittent VNS

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Headache

• One of the most common complaints
• More of a symptom than disease
• Stress response
• Vasodilation
• Skeletal muscle tension

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Types of Headaches

• Primary no organic cause
• Migraine
• Tension
• Cluster
• Cranial arteritis
• Secondary associated with a cause
• Brain tumor
• Aneurysm

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Migraines

• Recurring vascular-type headache characterized by
  unilateral or bilateral throbbing pain
• Cause not clearly demonstrated
• Occurs more commonly in women
• Strong familial tendency
• Typical time of onset is puberty
• Highest incidence ages 20 35

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Types of Migraines

• Migraine with aura
• Visual disturbances
• Parasthesias
• Motor dysfunctions
• Migraine without aura

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Clinical Manifestations

• Usually begins on awakening but can occur any
  time
• Migraine is divided in 4 phases
• Prodrome
• Aura
• The headache
• Recovery

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Clinical Manifestations

• Prodrome Phase
• Experienced by 60
• Symptoms occur hours to days before headache
• Depression
• Irritability
• Feeling cold
• Food cravings
• Anorexia
• Activity level changes

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Clinical Manifestations

• Aura Phase
• Occurs in about 20
• Lasts less than an hour
• Focal neurologic symptoms
• Visual disturbances
• Numbness and tingling in lips, face, or hands
• Mild confusion
• Slight weakness of an extremity
• Drowsiness or dizziness

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Clinical Manifestations

• Headache Phase
• Vasodilation and serotonin level declines
• Throbbing headache, severe and incapacitating
• Photophobia
• Nausea/Vomiting
• Duration 4 72 hours

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Clinical Manifestations

• Recovery Phase
• Pain gradually subsides
• Muscle contraction in the neck and scalp are
  common
• Muscle ache and local tenderness
• Exhaustion
• Mood changes
• Physical exertion exacerbates pain
• Extended sleep may occur

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Medical Management

• Therapy is abortive or preventive
• Abortive (symptomatic)
• Best for frequent attack sufferers
• Aim at relief or limiting headache at onset or
  while in progress
• Preventive
• Frequent attacks at regular or predictable
  intervals
• Would take these on a daily basis

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Medical Management

• Serotonin receptor agonists
• Most specific anti-migraine agents available
• Cause vasoconstriction
• Reduce inflammation
• May reduce pain transmission
• Examples
• Ergotamine
• Sumatriptan
• Dihydroergotamine

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Medications

• Ergot Alkaloids
• Ergotamine
• Dihydroergotamine
• Triptans
• sumatriptan (Imitrex)

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Prophylactic Treatment

• Antiepileptics
• Topamax, Depakote, Valproic Acid
• Antidepressants
• Amitriptyline, nortriptyline
• Antihypertensives
• Propranolol, Verapamil, Lisinopril, Candesartan
• Botulinum toxin A (Botox)

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Alternative Treatment

• Biofeedback
• Behavioral therapy
• Herbs
• Feverfew
• Petasites hybridus (herb Butterbur)
• Acupressure/acupuncture
• Massage/chiropractic
• Exercise

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Migraine Triggers

• Menstrual cycles
• Overuse of certain meds
• Foods with tyramine
• Milk products
• Aged cheese
• Wine Chocolate

• Fatigue
• Nitrites
• Bright lights
• Sleep deprivation
• Depression
• Processed foods
• Monosodium Glutamate

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Nursing Management

• Goals
• Administer medications to treat acute event
• Prevent recurrent episodes
• Patient education regarding precipitating factors
• Possible lifestyle or habit changes
• Pharmacologic measures

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Relieving Pain

• Early phase requires abortive medication therapy
  ASAP
• Ongoing phase includes
• Comfort measures
• Quiet room/area
• Dark environment
• Elevate HOB 30 degrees
• Antiemetics as needed

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Cluster Headache

• Severe form of vascular headache
• Most frequent in males ages 20 40 years
• Unilateral coming in clusters of 1 8 daily
• Watering of the eye and nasal congestion
• Attacks last 15 mins. to 3 hrs.
• May have crescendo decrescendo pattern
• Described as penetrating and steady

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Clinical Manifestations

• Excruciating pain (boring or piercing in nature)
• Orbital or supraorbital pain
• Eye tearing
• Tenderness of the temporal artery
• Facial flushing
• Elevated skin temperature on the ipsilateral side
• Very restless behavior

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Precipitators

• Alcohol
• Nitrites
• Vasodilators
• Histamines

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Medical Therapy

• Medication therapy
• Triptans
• Tricyclic antidepressants vasoconstrictors
• 100 oxygen _at_ 7 9 l/min for approx. 15 mins.
• Exercise
• Prophylactic therapy
• Calcium channel blockers (verapamil)
• Corticosteroids (prednisone, solumedrol)

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Cranial Arteritis

• Inflammation of cranial arteries
• Severe headache localized in region of temporal
  arteries
• Inflammation may be generalized (vascular
  disease)
• Inflammation may be focal (cranial arteries)
• Older population greatest incidence gt70

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Clinical Manifestations

• Fatigue
• Malaise
• Weight loss
• Fever
• Inflammation heat, redness, swelling,
  tenderness, or pain over affected artery
• Visible nodular temporal artery may occur
• Visual problems from ischemia

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Treatment

• Corticosteroids to prevent loss of vision due to
  vascular occlusion or rupture of involved artery
• Patient teach Abruptly stopping medication can
  lead to relapse
• Analgesics for comfort

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Tension Headache

• Contraction of the muscles in the neck and scalp
• Most frequent cause is stress
• Steady, constant feeling of pressure
• Described as band-like or a weight on top of the
  head
• Chronic rather than severe
• Probably most common type of headache

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Nursing Considerations

• Reassurance that the cause is not a brain tumor
• Employ stress reduction techniques
• Biofeedback
• Exercise
• Meditation
• Symptomatic relief of symptoms
• Local heat
• Massage
• Analgesics, antidepressants, muscle relaxants

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Neurologic Infections, Autoimmune Disorders, and
Neuropathies15-20 Questions

• Monti Smith, MSN, RN

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Neurologic Infections

• Meningitis
• Brain Abscess
• Infectious material in the brain
• Encephalitis

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Meningitis

• Inflammation of the meningeal tissues
• Classified as
• Bacterial gains access through bloodstream,
  wounds of the skull, fractures to the skull or
  sinuses
• Can be deadly!
• Viral cause is viral or secondary to lymphoma,
  leukemia, or HIV
• Commonly seen in colleges, military bases, etc.
  More common in the winter (b/c thats when you
  typically get more infections)

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Clinical Manifestations

• Headache
• Fever
• Nuchal rigidity
• Positive Kernigs sign
• When the pt is lying with their knee up to their
  stomach. The leg cant be completely extended.
• Positive Brudzinskis sign
• When you flex their neck, their knees and hips
  flex as well
• Photophobia

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Autoimmune Disorders

• Multiple Sclerosis
• Myasthenia Gravis
• Guillain-Barré Syndrome

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Multiple Sclerosis

• A progressive, degenerative disorder
  characterized by demyelination of nerve fibers of
  the brain spinal cord
• Cause is unknown, but thought to be related to
  genetics, infection, immunity
• Affects mostly women between 20-40
• Characterized by periods of remission and
  exacerbation
• Seen more in cold climates

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Types of Multiple Sclerosis

• Relapsing-remitting
• Most common
• These pts will tend to experience series of
  attacks or exacerbations followed by complete or
  partial remission
• Primary progressive
• Disease shows progression from onset with
  occasional plateaus and temporary minor
  improvements
• As soon as a pt finds out they have MS it is
  progressing
• Secondary progressive
• Chronic progressive form. No real periods of
  remission
• Small breaks with some relief
• Progressive-relapsing
• Worst one. Most commonly found in men
• Characterized by gradual decline, no real periods
  of remission

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Early Symptoms(Common early S/S)

• Tingling (lasts a few days usually)
• Numbness (lasts a few days usually also)
• Loss of balance
• Blurred or double vision (very common. A lot of
  times people will go to the eye dr for this and
  the eye dr guy sends them in to be checked for
  MS)
• Weakness in one or more limbs

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Clinical Manifestations Motor

• Fatigue and stiffness of extremities
• Spacticity
• Hyperactive deep tendon reflexes
• Positive Babinskis reflex
• Visual difficulties
• Could be blurred vision, double vision, decreased
  visual acuity, nystagmus (googly eyes)
• Intention tremor
• I dont usually have a tremor all the time, but
  when I go to perform an activity (like picking up
  a cup) I get the tremor
• Unsteady gait
• Dysmetria
• Inability to direct or limit movement. Like I
  want to go one way but I cant

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Clinical Manifestations Sensory

• Facial pain
• Numbness
• Tingling
• Burning
• Bladder function changes
• Can be urgency, frequency, having to pee a lot at
  night
• Bowel function problems
• Problems with sexuality
• Impotence, decreased vaginal secretions, etc.

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Clinical Manifestations Cognitive

• Inattentiveness
• Impaired judgment
• Decreased concentration
• Decreased short-term memory
• Decreased ability to perform calculations

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Assessment Diagnostic Findings

• MRI
• They are looking for Demylenating plaques (called
  MS plaques) in the brain, neck, and spine. A lot
  of the times you can tell from the symptoms where
  the problem might be. Vision problems head.
  Tingling neck. Leg problems spine.
• CSF analysis
• Evoked potential studies
• Neuropsychological testing
• How bad are your cognitive impairments?
• Sexual history

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Medical Management

• No cure
• Goals of treatment delay progression of disease,
  manage chronic symptoms, treat acute
  exacerbations
• Management strategies target various motor
  sensory symptoms effects of immobility
• Some people may only take one thing a week to
  prevent progression while not in an exacerbating
  stage. Others have to be on super tons of stuff
  all the time. It just depends on the person

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Pharmacologic Treatment

• Disease-modifying
• Betaseron, Avonex, Rebif, Copaxone, Novantrone,
  Methylprednisolone
• Symptom management (spasticity)
• Baclofen
• Valium
• Zanaflex
• Dantrium

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Pharmacologic Treatment Cont.

• Symptom management (urinary problems)
• Urecholine
• Prostigmin
• Ditropan
• Symptom management (CNS stimulants) (to try and
  fight the symptoms of fatigue)
• Cylert
• Ritalin
• Provigil
• Amantadine

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Nursing Interventions

• Promote physical mobility
• Walking, stretching, swimming, stationary bikes.
  Do things that arent strenuous because the quick
  stuff can make their spasticity worse (which is
  bad). Plan rest and activity accordingly
• MS pts do poorly if their body temp goes up. The
  higher the temp, the worse their symptoms.
• Prevent injury
• MS causes a lot of problems with incoordination
  and their gate. They may have to use assistive
  device
• Enhance bowel bladder control
• May require training
• Enhance communication
• Like for someone in a progressive form, might
  have problems with their communication. She
  hasnt really seen this
• Improve sensory cognitive function
• Teach about medications
• Educate family

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Myasthenia Gravis

• Definition An autoimmune disease that involves
  a decrease in the number and effectiveness of
  acetylcholine receptors at the neuromuscular
  junction
• Antibodies are found in 80-90 of people with
  myasthenia gravis (MG)
• 80 of pts diagnosed with MG end up having
  thymus gland problems (could be hyperplasia or a
  tumor which is called a thymoma)
• Thymus gland is believed to be where these
  antibodies are produced
• Etiology Although unclear, research strongly
  suggests cause is antibodies to acetylcholine
  receptors
• When someone has MS their immune system makes
  antibodies that damage or block many of the
  muscles acetylcholine receptors. The effected
  muscles dont work as well as they would normally
  if they had all the acetylcholine receptors

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Incidence of MG

• Not hereditary
• May have 5 familial incidence
• Onset before age 10 or after age 60 is rare
• Peak age between 20-30 years
• Women affected 3 times more often than men if
  onset before age 40

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Clinical Manifestations

• Extreme skeletal muscle weakness
• Usually of the bigger muscles. May have trouble
  getting up from sitting. Waxing/waning of this.
  Worsen with use and improves with rest. This is a
  hallmark sign of the disease! Muscles are usually
  stronger in the morning and weaker in the evening
• Fatigability
• Diplopia (double vision)
• Ptosis (drooping of the eyelid)
• Sleepy, mask like expression.
• Could have changes in expression or speech,
  difficulty with mastication (chewing).
• Dysphonia (voice impairment)
• Extremity weakness
• Sometimes they cant even keep their head up b/c
  their neck is super weak
• Respiratory weakness
• Bulbar the combination of the chewing,
  swallowing, speech stuff. This could be bulbar
  weakness or whatever to describe weakness in
  these three places

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Diagnostic Findings in MG

• History physical exam
• Tensilon test
• Tensilon facilitates the transmission of impulses
  at the myo-neural junction leading to temporary
  improvement of symptoms. Its administered IV
• Their eye is droopy and you give them this and
  their eye isnt droopy anymore. Then after a few
  mins the eye is droopy again.
• Tensilon inhibits the breakdown of acetylcholine.
  It can cause V-fib and cardiac arrest. Make sure
  you have atropine in case that happens and you
  need to give it!
• Acetylcholine receptor antibodies
• They take your blood and do a test. About 80-90
  of pts with MG will test positive for these guys
• Electromyography (EMG)
• Stick a needle in your muscle and they do tests
  and things to see how your muscles are working
• CT scan, MRI

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Medical Management

• Anticholinesterase medications
• Mestinon
• Immunomodulating drugs
• Prednisone
• Cytoxic medications
• Imuran, Cytoxan, Neoral

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Medical Management

• Plasmapheresis
• Used to treat exacerbations. Done IV. Take the
  plasma and plasma components (kind of like
  dialysis). They separate the blood cells and the
  antibodies, then they put the blood back in. This
  simply reduces the number of circulating
  antibodies. In about 75 of pts this gives them
  great improvement, but its only temporary
• IV immune globulin
• They dont think it works that great, and its
  very expensive. So they dont do this much
• Thymectomy
• They go in and remove your thymus gland. Its in
  your chest, they have to go crack your ribs to
  remove it. Can give you partial or complete
  remission. Can take up to 3 years to have the
  full effects from the surgery (for all the
  antibodies to get out of your blood stream). Can
  combine this with plasmapheresis to help

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Crises in MG

• Myasthenic Crisis
• Acute exacerbation of muscle weakness caused by
  inadequate dose of anticholinergic medications,
  infection, stress, or surgery
• Not enough
• Cholinergic Crisis
• Cause by overmedication with cholinergic drugs
• Too much
• Symptoms are the same in both so you can tell the
  difference with a tensilon test. Important to get
  a Hx

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Nursing Client Education

• Educate on importance of medication management
• Teach energy conservation strategies
• B/c pt fatigues easily
• We need to encourage things like handicap
  stickers
• Tell them to do stuff when their strength is at
  its best (usually in the mornings)
• Instruct on strategies to prevent ocular
  manifestations
• Use eyedrops, wear patches at night to keep the
  eyelids closed, surgery, etc.
• Educate on ways to minimize risks of aspiration
• Plan meal times around medications!
• Remind client of the importance of maintaining
  health promotion practices

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Nursing Diagnoses

• Ineffective breathing pattern
• Ineffective airway clearance
• Impaired physical mobility
• Impaired verbal communication
• Constipation and other bowel dysfunctions
• Self care deficit
• Altered nutrition

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Guillain-Barré Syndrome

• An acute inflammatory process characterized by
  varying degrees of motor weakness and paralysis
• An autoimmune attack on the peripheral nerve
  myelin
• Mortality generally results from complications of
  respiratory compromise
• Typically begins with muscle weakness and starts
  at the bottom of the body
• Cause is unknown, but could be a viral infection,
  trauma, surgery, or an immunization, but who
  knows

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Clinical Manifestations

• Ascending weakness (starts at the bottom and
  works its way up)
• Parasthesias, hypotonia, areflexia (no
  reflexes) of extremities
• May see bulbar weakness such as paralysis of
  ocular muscles inability to swallow
• Worst case scenario respiratory failure
• Weakness may start and then peak on the 14th day.
  Can be longer, can be shorter

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Assessment Diagnostic Findings

• History physical
• Key is that its travelling up the body!
• Elevated protein in CSF
• They would find this during a lumbar puncture
• Abnormal EMG
• Reduced nerve conduction

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Medical Management

• Airway maintenance (most important thing!!!! If
  they have ascending paralysis it could paralyze
  their diaphragm and if that happens then they
  cant breathe)
• Intravenous Immunoglobulin (IVIG)
• Plasmapheresis
• Provide range of motion for clients with
  decreased mobility
• Prevent pulmonary emboli
• Encourage independence with ADLs
• Most people recover b/w 6 months to a year. But
  it can come back! That is a long recovery time.
  Sometimes it plateaus 4 to 6 weeks, in some cases
  1 year.

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Nursing Diagnoses

• Ineffective breathing pattern
• Impaired physical mobility
• Impaired verbal communication
• Fear and anxiety related to paralysis
• Imbalanced nutrition, less than body requirements

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Peripheral Neuropathies

• Disorder affecting the peripheral sensory
  nerves characterized by bilateral symmetric
  disturbance of function, usually beginning in the
  feet hands
• Symptoms loss of sensation, muscle atrophy,
  diminished reflexes, pain, parasthesias
• Causes systemic diseases, vitamin deficiency,
  drug toxicity, infections, trauma, heavy metals,
  and exogenous substances

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Restless Legs Syndrome

• Characterized by leg parasthesias associated with
  an irresistible urge to move
• Common in iron deficiency, renal failure, DM,
  rheumatic disorders, pregnancy
• Complaints of intense burning or crawling-type
  sensation

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Management of RLS

• Sinemet
• Mirapex
• Requip
• Clonidine
• Clonazepam
• Some antiseizure meds

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Cranial Nerve Disorders

• Trigeminal Neuralgia (Tic Douloureux)
• Very, very painful!!
• Affects the trigeminal or 5th cranial nerve
• Cause unclear Suspect
• Compression of 5th nerve by a vein or artery
• Injury to the trigeminal nerve
• Herpes Virus (HHV6)

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Managing Trigeminal Neuralgia

• Determined by amount of pain experienced. Usually
  unilateral but can be on both sides
• Nonsurgical
• Carbamazepine
• Baclofen
• Amitriptyline
• Surgical
• Janetta procedure arterial decompression
• Radiofrequency percutaneous electrocoagulation

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Bells Palsy

• Definition Acute paralysis of cranial nerve VII
  (facial)
• Age is not a factor
• Onset is acute
• Maximal paralysis within 48 hrs 5 days
• Cause unclear possibly result of inflammatory
  process

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Managing Bells Palsy

• Prednisone
• Analgesics for pain
• Avoid corneal abrasion by use of eye ointments
  and patch or tape
• Use straws to diminish drooling
• Warm moist heat
• Facial exercises
• 80 full recovery

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Degenerative Neurologic Disorders
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Parkinsons Disease

• Definition A slowly progressing neurologic
  movement disorder eventually leading to
  disability
• Degenerative or idiopathic form is most common
• Cause is unknown
• Research suggests genetics, atherosclerosis,
  excessive accumulation of oxygen free radicals,
  viral infections, head trauma, chronic
  antipsychotic medication use, environmental
  exposures
• More men than women, symptoms usually show up in
  the 50s

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Pathophysiology

• Associated with decreased levels of dopamine
• Loss of dopamine stores result in more excitatory
  neurotransmitters than inhibitory
  neurotransmitters imbalances that affect
  voluntary movement
• Clinical symptoms appear with 60 neuron loss and
  80 dopamine decrease

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Clinical Manifestations

• Classic Symptoms (triad)
• Tremor (often the 1st sign)
• Usually seen first at rest, and then aggravated
  by stress. Like a booger rolling tremor
• Rigidity
• Increase resistance to passive motion. You try to
  move them and they get stiff
• Bradykinesia
• Automatic movements are super slow. This accounts
  for their stooped posture, shuffled gait. They
  also have no arm swings when they walk
• Another important symptom
• Postural instability (propulsive gait, they lean
  too far forward when they walk, like their
  balance is off. Their head is too far forward and
  they lose their balance very easily)
• Other manifestations
• Shuffling gait
• Dysphonia

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Other Manifestations

• Excessive uncontrolled sweating
• Orthostatic hypotension
• Gastric urinary retention, constipation
• Sexual dysfunction
• Psychiatric disorders
• Depression, dementia, memory deficits,
  personality changes. They have a lot of
  hallucinations (can be b/c of meds)
• Sleep disorders
• A lot of times related to their medications

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Diagnostic Findings

• Diagnosed clinically from patient history,
  presence of 2 3 cardinal manifestations
  tremor, muscle rigidity, bradykinesia
• Family notices changes such as stooped posture,
  stiff arm, slight limp, tremor, handwriting
  differences
• Medical history, presenting symptoms, neurologic
  exam, response to pharmacologic management are
  carefully evaluated

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Medical Management

• Levodopa
• Anticholinergics
• Dopamine agonists
• Monoamine Oxidase Inhibitors
• Catechol-O-Methyltransferase Inhibitors
• Antidepressants

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Surgical Management

• Thalamotomy
• Improve tremor and rigidity
• Pallidotomy
• Improve tremor and rigidity, not for demented
  people, they go in and burn stuff
• Deep brain stimulator
• Like a pacemaker thing in your brain
• The first two are permanent, once its done its
  done. The DBS can be turned on or off or moved
  from place to place

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Nursing Diagnoses

• Risk for falls
• Self-care deficit
• Chronic confusion
• Impaired physical mobility
• Impaired verbal communication
• Risk for imbalanced nutrition Less than body
  requirements

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Huntingtons Disease

• Chronic, progressive, hereditary disease of the
  nervous system that results in progressive
  involuntary choreiform (dance like) movement and
  dementia
• It is transmitted as an autosomal dominant
  genetic disorder, each child of a parent with
  the disease has a 50 risk of inheriting the
  disorder (very genetic!! But you usually dont
  know you have it until you have children)

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Pathophysiology

• Premature death of cells in the striatum of the
  basal ganglia
• Researchers believe glutamine abnormally collects
  in the cell nucleus causing cell death
• Onset between the ages of 35-45
• Slowly progressive disease
• Patients usually become emaciated exhausted
• Because they are dancing around all day long
  uncontrollably!
• Death after 10 20 yrs

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Clinical Manifestations

• Abnormal involuntary movements (chorea)
• Increasing intellectual decline
• Emotional disturbance
• Constant writhing, twisting, uncontrollable
  movement of the body
• Facial tics grimaces
• Slurred, he