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Migraine headache
- chronic, episodic disorder with multiple subtypes
- more frequent in women
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Stages of migraines
- prodrome - mood change
- aura phase
- headache phase - can last hours to days; typically unilateral
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Pathophysiology of migraines
- not completely understood
- inflammation
- substance P released
- affects trigeminal nerve
- vasodilation
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Interventions for migraines
- recognize migraine symptoms
- see a health care provider
- relieve pain and associated symptoms
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Abortive drug therapy for migraines
- alleviating pain during early aura phase or soon after headache has started
- Imitrex
- caffeine
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Preventive therapy for migraines
- if suffering from more than 2 a month, preventive therapy needs to be initiated
- beta blockers
- calcium channel blockers
- elavil
- treat HTN - headaches generally decrease
- antiseizure meds
- prevent triggers - no tyramine, hysterectomy
- antiinflammatories - high dose ibuprofen for mild migraines
- reglan, phenergen for nausea
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CAM therapies for migraines
- yoga, meditation, massage, exercise, biofeedback, relaxation, pressure points
- acupuncture
- herbs
- reduce tension/stress
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Cluster headache
- more frequent in men
- unknown cause but attributed to vasoreactivity and oxyhemoglobin desaturation
- histamine cephalalgia
- unilateral, radiating to forehead, temple or cheek
- ipsilateral tearing of the eye, rhinorrhea, ptosis and miosis
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Therapy for cluster headaches
- same drugs as for migraines
- sunglasses
- oxygen via face mask
- avoid precipitating factors - anger; excitement
- possible surgical management
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Tension headache
- neck and shoulder muscle tenderness and bilateral pain at base of skull and in forehead
- head pain without associated symptoms
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Treatment for tension headache
- non-opioid analgesics, muscle relaxants, occasional opioids
- ibuprofen + caffeine
- prophylactic similar to migraine treatment
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Seizure
- abnormal, sudden, excessive, uncontrolled electrical discharge of neurons within the brain
- may result in alteration of consciousness, motor or sensory ability and/or behavior
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Epilepsy
- two or more seizures experienced by a person
- chronic disorder with recurrent, unprovoked seizure activity
- may be caused by abnormality in electrical neuronal activity and/or imbalance of neurotransmitters
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Biggest concerns when a seizure occurs?
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Types of seizures
- generalized
- partial
- unclassified
- primary or idiopathic epilepsy
- secondary
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Generalized seizures
- both cerebral hemispheres affected
- tonic/clonic
- absent seizures
- myoclonic
- atonic
- extreme exhaustion
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Myclonic
brief jerking in seizure
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Atonic
loss of muscle tone and client falls down in seizure
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Partial seizure
starts in one part of the brain but it can spread
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Primary or idiopathic epilepsy
- not associated with any identifiable brain lesion
- cause is often unknown
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Secondary seizure
results from an underlying brain lesion - most commonly a tumor or trauma
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Seizure risks
- metabolic disorders
- acute alcohol withdrawal
- electrolyte disturbances - especially sodium
- heart disease
- high fever
- stroke
- substance abuse
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Status epilepticus
- prolonged seizure lasting more than 5 minutes or repeated seizures over course of 30 min
- airway/breathing is top priority
- medical emergency
- ABGs
- IV push lorazepam, diazepam
- Loading dose of IV phenytoin - no warfarin with phenytoin
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Non-surgical management of seizures
- antiepileptic drugs
- - dilantin
- - tagertol
- - neurontin
- - draw peak and trough often
- teach compliance - same time each day and to keep lab appointments
- define triggers
- wear a medical alert bracelet
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Seizure precautions
- oxygen and suctioning equipment readily available
- saline lock
- siderails up at all times
- possibly padded siderails
- bed locked and in lowest position
- no tongue blades during seizure!!
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Seizure management
- simple partial - observe client and document seizure
- turn patient on side during generalized tonic-clonic seizure and turn head to prevent aspiration
- cyanosis is usually self limiting
- do not restrain
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Acute seizure management
- lorazepam
- diazepam
- diastat
- IV phenytoin
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Surgical management of seizures
- vagal nerve stimulation
- conventional - cut between hemispheres - last resort
- anterior temporal lobe resection
- partial corpus callostomy
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Meningitis
- inflammation of meninges that surround the brain and spinal cord
- dorm living = high risk
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Viral meningitis
- usually self limiting and patient has complete recovery
- not a lot of treatment
- most common cause is Herpes 2
- patient on droplet precautions
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Bacterial meningitis
- potentially life threatening
- antibiotics
- immunizations prevent it
- most common causes are S. pneumonia and N. meningitis
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Physical assessment/clinical manifestation of meningitis
- headache, N/V, fever, photophobia, increased ICP
- Nuchal rigidity and positive Kernig's and Brudzinski's signs
- seizure
- decreased mental status
- focal neurologic deficits
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Brudzinski's sign
- have patient lay down and flex their neck
- if their legs flex in response the test is positive
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Kernig's sign
- patient laying down flat
- flex knee
- if there is pain on knee extension the test is positive
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Labs for meningitis
- CSF analysis
- CT scan
- Blood cultures - sugar low in bacterial; protein high in viral
- Counterimmunoelectrophoresis
- CBC
- X-ray
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Drug therapy for meningitis
- Broad spectrum antibiotics
- hyperosmolar agents to shift fluid out of brain
- anticonvulsants
- steroids
- prophylaxis for those in contact with infected patient
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Encephalitis
- inflammation of brain tissue and surrounding meninges
- caused by virus, bacteria, fungi or parasites - West Nile virus
- degeneration of neurons of cortex
- hemorrhage, edema, necrosis, small lacunae develop in cerebral hemispheres
- confusion
- possible persistent neuro problems after recovery
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Interventions for encephalitis
- prompt recognition and treatment of signs of cerebral edema, hemorrhage and necrosis of brain tissue
- patent airway
- VS - widened pulse pressure, bradycardia
- safety measures
- quiet room
- HOB up
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Parkinson disease
- progressive neurodegenerative disease
- 3rd most common neurological disorder in older adults
- tremor, rigidity, bradykinesia or akinesia
- imbalance between dopamine and Ach (not enough dopamine)
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Assessment for Parkinson's
- fatigue
- slight tremor
- problems with manual dexterity
- rigidity
- changes in facial expression
- uncontrolled drooling
- dementia
- changes in voluntary movement
- excessive perspiration
- orthostatic hypotension
- pill rolling
- mask like face
- staring eyes
- no specific diagnostic tests
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Drug therapy for Parkinson's
- dopamine agonists
- COMTs
- MAO-B inhibitors
- dopamine receptor antagonists
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Drug toxicity risk in Parkinson's therapy
- long term therapy often causes delirium, cognitive impairment, decreased effectiveness of meds or hallucinations
- reduce the dose or change meds/frequency of administration
- take "drug holiday"
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Management of Parkinson's
- exercise, ambulation
- self-management/care
- injury prevention
- nutrition - swallow therapy
- communication
- psychosocial support
- possible surgical management
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Alzheimer's
- chronic, progressive, degenerative disease that accounts for 60% of dementia occurring in 65 or older
- loss of memory, judgment and visuospatial perception
- change in personality
- increasing cognitive impairment, severe physical deterioration and death from complications of immobility
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Structural changes in brain for Alzheimer's
- neurofibrillary tangles
- neuritic plaques
- vascular degeneration
- changes in neurotransmitters
- increased amounts of beta amyloid - abnormal protein
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Manifestations of Alzheimer's
- changes in cognition
- alterations in communication and language abilities
- changes in behavior, personality and judgment
- changes in self-care skills
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Interventions for Alzheimer's
- answer patient's questions honestly
- assess and treat other medical problems
- provide cognitive stimulation and memory training
- structure environment to increase functioning
- prevent overstimulation
- orientation/validation therapy
- promote self-management
- promote bowel/bladder continence
- assist with facial recognition
- promote communication
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Drug therapy for Alzheimer's
- Donepezil (Aricept)
- Abilify
- Namenda
- antidepressants
- psychotropic drugs
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Preventing injury for Alzheimer's
- cope with restlessness/wandering
- patient identification bracelet
- register in safe return program
- frequent walks and structured activities to reduce wandering
- SAFETY
- minimize agitation
- display positive affect
- calm movements
- offer diversions
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Interventions to help the caregiver for an Alzheimer's patient
- encourage family to seek legal counsel regarding patient competency, need to obtain guardianship or durable power of attorney, when necessary
- make caregivers/family aware of own health and stress resulting from new responsibilities for care
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Interventions for disturbed sleep patters in Alzheimer's
- re-establish day-night pattern by providing activity and exercise during day
- establish before bedtime ritual
- adjust treatment and medication schedule to provide for uninterrupted sleep
- give mild antianxiety agent or hypnotic
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Huntington disease
- hereditary disorder transmitted as an autosomal dominant trait at time of conception
- movement disorder characterized by both neurologic and behavioral symptoms
- gradual clinical onset of progressive mental status changes leading to dementia and choreiform movements in the limbs, trunk, and facial muscles
- three stages - each lasting about 5 years over an average of 15 years of the disease
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Management of Huntington disease
- no known cure or treatment
- genetic counseling
- antipsychotic agents or monamine depleting agents used to manage movement abnormalities that are disabling or interfere with ADLs
- medications to treat depression, anxiety and OCD behaviors
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