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What causes ALS?
it is a degeneration and demyelination of MOTOR neurons of the spinal cord and brainstem causing the muscles they connect to to weaken, experience atrophy and then die
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S/S of ALS
- Weakness/paresis that starts distally then moves to trunk
- dysphagia
- dysarthria
- emotion labiality, but not dementia
- Respiratory compromise
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To sum up ALS the person will experience....
- progressive weakness
- muscle wasting
- spasticity
- paralysis
- respiratory compromise
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Why does a person with ALS have dysphagia and dysarthria?
cuz theres progressive atrophy of the tongue and facial muscles
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What does the person with ALS have respiratory compromise?
Cuz muscles of the trapezius and sternocleidomastoid atrophy.....this can lead to PNA and death
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What happens to a person with ALS ability to go to the bathroom?
bowel and bladder stay in tact, but the person will need a way to communicate to you they need to use the restroom-blink
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If you have a dysfunction of upper motor neurons you will have problems with....
- spastic/weak muscles
- loss of voluntary movements
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If you have a dysfunction of lower motor neurons you will have problems with
- flaccid muscles
- paralysis
- atrophy
- twitching
- breathing problems
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Who usually gets ALS?
men between 40-70....death occurs within 3 years
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Two major problems with ALS
Respiratory failure and aspiration
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As a nurse it is very important to manage these things in a person with ALS
- maintain an open airway
- provide adequate nutrition minimizing risk for aspiration
- speak early about end of life
- get an AD in place
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First medications used on a person with ALS?
Neostigmine/Prostigmine-Anticholinergics
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Why is Baclofen given to a patient with ALS?
It is a muscle relaxer
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Why is Rilutek given to a patient with ALS?
How do you take it?
What do you monitor?
It will extend their survival time so they can attend an important even.
- 50mg/2x day on an empty stomach
- Monitor LFT's
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What does a person with ALS usually die from?
respiratory infection
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What is a seizure?
a paroxysmal(sudden), uncontrolled electrical discharge of neurons in the brain that interrupts normal function
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What's epilepsy?
a chronic disorder of recurrent seizures
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Who is most likely to get epilepsy?
Poor African American Males
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What makes a person at high risk for Epilepsy?
- if you have 1 parent with epilepsy
- if you have Alzheimers disease with a stroke
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What typically causes seizures if you are 2-20 years old?
- birth injury
- infection
- trauma
- genetic factors
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What typically causes seizure if you are 20-30 years old?
- structural lesions
- trauma
- brain tumor
- vascular disease
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What typically causes seizures if you at over 50?
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How can you be screwed when it comes to families and seizures?
Everyone has a different seizure threshold which is inherited.
Seizure threshold is activated by trauma, disease or fever
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What's generalized seizure?
a seizure that involves the entire brain
person has a loss of consciousness for a few seconds to several minutes
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Gliosis
scar tissue in the brain that is oftenly a common area where epileptic activity arises
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What are the effects of seizures on the brain?
Result?
increased metabolic demand requiring 4x as much glucose and oxygen....if unmet cellular destruction can occur
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4 stages of a seizure
- prodroma
- aural
- ictal
- postictal
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prodromal seizure phase
signs or activity that precede a seizure
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aural seizure phase
a sensory warning prior to seizure
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ictal seizure phase
full seizure
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postictal seizure phase
period of recover after the seizure....usually sleepy and not talking
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Tonic Clonic seizure
used to be Grand Mal
- loss of consciousness
- pt. falls to ground and stiffens up (tonic) for 10-20 seconds then jerks around (clonic) for another 30-40 seconds
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What are the s/s of a tonic clonic seizure?
- cyanosis
- excessive salivation
- tongue or cheek biting
- incontinence
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Absence seizure
usually occurs in kids.....can have up to 100/day
seen as a staring spell so can go unnoticed
**usually grow out of by adolesence
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What usually precipitates an absence seizure?
- hyperventilation
- flashing lights
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Myoclonic Seizure
sudden excessive jerking of the body or extremities causing the person to hurl themselves to the ground
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Atonic Seizure
Drop ATTACK
- tonic episode or paroxysmal loss of muscle tone
- consciousness usually returns with ground contact
**wear protective helmet
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Simple partial seizure
doesn't involve loss of consciousness and lasts less than 1 minute
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Complex partial seizure
can involve a variety of behavioral, emotional and affective and cognitive functions
Lasts more than 1 min....then person has postictal confusion
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What is the most common partial seizure?
What happens?
Automatism
person lip smacks, picks or does some sort of repetitive motion
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How do you describe a seizure?
- onset
- duration
- frequency
- postictal state
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If a person has a seizure disorder make sure you find out....
- birth and development history
- seizure history....precipitating factors, antecedent events, seizure description
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What is the starting point test for seizure diagnosis?
lumbar puncture of CSF
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What two electrolytes can trigger seizures?
hyponatremia and hypoglycemia
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Medications for seizures do what?
control seizures, but don't cure disorder
stabilize nerve cell membranes preventing spread of the epileptic discharge
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Drug therapy for seizures is based on....
- type
- frequency
- cause....of seizures
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4 things to know about Keppra for seizures
- dosage is based on weight
- educate patient to know why it is important to not miss meds
- stopping abruptly can trigger a seizure
- must be weaned with dr. assistance
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If a person is on Dilantin for seizures don't....
have them on D5 for IV....icicles
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Important info about anti seizure meds:
- abrupt withdrawl can cause seizure
- to go off you must be seizure free for 2-5 yrs
- have a normal EEG
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Common seizure med side effects:
- diplopia
- drowsiness
- ataxia
- mental slowing
- skin rash
- gingiva (hyperplasia)
- blood dyscrasias
- liver/kidney issues
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If you think a person has a toxic level of ant seizure meds you can check them bye....
- checking eyes for nystagmus
- check hand and gait coordination
- cognitive fxn
- general alertness
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Dilantin S/E
- gingival hyperplasia
- hirsutism
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What is gingival hyperplasia?
How do you minimize it?
excessive growth if gingival tissue
good dental hygiene with brushing and flossing and dental visits
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What's hirsutism?
excessive hair on a woman
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What do you do for a patient who is having a seizure?
- protect from injury....especially the head
- turn on side to keep airway open
- have O2 and suction available in patients room
- emotional support for patient
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Monitoring a person during/after seizure
- Note time of onset, duration of seizure, precipitating factors, aura if any
- Note body parts involved...pupil size, reactivity, respirations, cyanosis
- Incontinence
- Salivation
- LOC during and after seizure
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After a seizure....
- check arousability
- Neuro check (Glascow Coma)
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Postictal state lasts how long and what will the person be like?
- 30-90 min
- confused
- exhausted
- asleep
- sore muscles
- weak
- aphasia
- inability to maintain airway if not arousable
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Status Elipticus
ongoing continuous seizure activity without return to consciousness between seizures
Medical Emergency!!!
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Why is status elepticus a medical emergency
- the brain is using more than it is supplied which can cause:
- Permanent brain damage
- ventilator insufficiency
- hypoxemia
- cardiac dysrhythmias
- hyperthermia
- systemic acidosis
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Rapid acting IV anti seizure meds
- Ativan
- Valium
- Propofol (Dr. admin only)
Will be followed by long acting drugs like Phenytoin
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When can a person get their drivers license back once they are seizure free?
6 mo. 1 yr seizure free
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Phenytoin affects what commonly used medication?
Coumadin
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Which anti seizure meds need peak and trough blood tests?
- Keppra
- Phenobarbital
- Phenytoin
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Vagal Nerve Stimulation for seizures
- electrode implanted in neck that delivers electrical impulses to nerve which prevent seizures
- patient activates device with magnet when seizure is sensed
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AEIOU for seizures
- Alcohol
- Epilepsy
- Infection/Inflammation
- Overdose
- Underdose
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TIPS for seizures
- Trauma
- Ischemia
- Psychiatric
- Stroke
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What's Parkinsons?
chronic progressive neurodegenerative disorder characterized by slowness in the initiation and execution of movement
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4 signs of Parkinsons
- bradykinesia
- rigidity
- tremors at rest
- Gait disturbance
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What is the problem with Parkinsons?
person has low dopamine and an imbalance with ACh
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Who's at risk to get Parkinsons?
Men....it is inherited
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Chemically induced Parkinsonism is associated with
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Drug induced Parkinsons
- it is temporary...but will see it when a patients on
- Lithium
- Haldol
- Thorazine
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Which illicit drug use can cause Parkinsons symptoms?
Amphetamines and Methamphetamines
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What does dopamine do?
allows for smooth movements....not enough in Parkinsons
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People with Parkinsons will have problems with
- hand tremors/pill rolling
- akinesia
- respiratory problems
- difficulty swallowing/chewing
- soft voice
- poor balance
- gait disturbance/diminished arm swing
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Common non motor symptoms of Parkinsons
- depression
- anxiety
- apathy
- fatigue
- pain
- constipation
- impotence
- short term memory impairment
- sleep disorder
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40% of patients with Parkinsons have
dementia
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What happens with eating with a parkinsons patient?
- swallowing becomes more difficult so...
- malnutrition
- aspiration
- PNA
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What Parkinsons meds can only be used for less than 3 years?
- Levodopa
- Carbidopa
- Parlodel
- Requip
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S/E of Dopaminergic meds for Parkinsons
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Dopamanergics for Parkinsons relieve which symptoms?
- Bradykinesia
- Tremors
- Rigidity
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What can Benadryl do for a Parkinsons patient?
decrease tremors and rigidity
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Why are people with Parkinsons a fall risk?
How do I help?
they freeze while walking...
- teach them to consciously think about stepping over imaginary lines on the floor
- drop rice kernels and step over them
- rock from side to side
- lift toes when stepping
- take one step backwards and 2 steps fwd
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When do you do surgery for Parkinsons?
Describe....
no response to meds or have developed sever motor complications
- Ablation
- Deep brain stimulation
- Transplantation of fetal neural tissue
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How should a person with Parkinsons eat?
- 6 small meals
- bite sized foods
- easy to chew and swallow
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Person with Parkinsons has decreased mobility causing
- constipation
- ankle edema
- contractures
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Person with general debilitation from Parkinsons is at risk for
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Orthostatic hypotension puts a person at risk for....
falls/injuries
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People with Parkinsons will probably die from....
- PNA
- Septic from skin breakdown infection
- fall
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What's Guillain Barre?
an acute possibly fatal inflammation that destroys the myelin sheath of nerve impulses caused by and immune response (bacterial/viral)
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Pathological process of Guillain Barre
starts at ascending or descending....ends up with respiratory compromise
but will plateau then the person recovers 4-6 months later....up to 95% full recovery
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What is overtaxed with GB?
T cells
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Why can you take a CSF sample to dx GB?
cuz it will show protein levels. Myelin sheath is a protein which will show up in the CSF when it is degenerated
Normal is 15-45mg/dL
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Signs of Ascending GB
weakness and numbness with respiratory compromise
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Signs of Descending GB
- weakness with bulbar muscles
- descends to limbs then the respiratory muscles
- muscle atrophy
- DVT
- Pulmonary emboli
- skin breakdown
- nutritional deficiencies
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Options for treating GB
- Sandoglobulin
- Plasmapheresis
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Key management for a person with GB
- Vital Capacity (<800)
- ABG
- Ventilator
- TCDB
- Oral Care
- PNA?
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Who is at risk for getting GB?
Person with a URI or GI infection in past 1-3 weeks.
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Complications of GB
- respiratory failure from paralysis of thoracic area
- respiratory/UTI infections
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Things to monitor for with GB
- Respiratory failure
- Aspirations
- Urinary output
- monitor for illeus
- immobility
- infection
- communication
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Encephalitis
inflammation of the brain tissue and often the meninges caused by a virus, bacteria, fungi or parasites
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Patho of encephalitis
Virus/bacteria enters brain to blood stream to nerves causing inflammation and degredation of neurons and demylenization of axons causing hemorrhage, edema and increased ICP
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Clinical manifestations of Encephalitis
- fever
- N/V
- headache
- vertigo
- confusion
- personality changes
- seizures
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What happens if you don't treat encephalitis?
Increased ICP
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Nursing care for a person with Encephalitis
- frequent neuro checks
- assess for signs of ICP increase
- Systolic BP, decreased HR
- maintain patent airway
- HOB at 30
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What causes Trigeminal Neuralgia?
compression of blood vessels from chronic irritation of CN #5 at the root entry zone causing an increase in firing of sensory fibers
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S/S of Trigeminal Neuralgia
PAIN!!!
- It is unilateral.
- It comes and goes
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What triggers Trigeminal Neuralgia?
- touch
- brushing teeth
- shaving
- eating
- talking
- exposure to cold or wind
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What medications are given to patients with Trigeminal Neuralgia?
Why?
- Anti Seizure meds....
- Tegretol, Dilantin, Valproate
acts on sodium channels decreasing neuron firing
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If a persons on Tegretol, Dilantin or Valproate what labs do I need to check periodically?
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Keep in mind for a patient with Trigeminal Neurologia....
- Pt. may neglect their hygiene
- Encourage to perform hygiene tasks during peak analgesia times
- Eat foods high in protein and calories, easy to chew
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What is an odd problem with Trigeminal Neurologia....what do I do to help?
corneal reflex....
artificial tears or eye shield
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Bell's Palsy
Inflammation of CN #7 (facial) usually caused by herpes
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Clinical Manifestations of Bell's Palsy
- fever
- tinnitus
- drooping mouth/drooling
- loss of tearing
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Complications of Bell's Palsy
- psychologic withdrawl
- malnutrition/dehydration
- corneal abrasions
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Medication used immediately to treat Bell's Palsy
Corticosteroids-Prednisone
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Special considerations for people with Bell's Palsy
- artificial tears
- eye shield?
- wear shield or tape eye shut at night
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Name an antiviral medication to treat herpes
Acyclovir
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What is a patient given to decrease cerebral edema?
Decadron
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What is commonly given to patients to prevent or control seizures
Dilantin
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What is given to patients to control hyperthermia and headache
Tylenol
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Artificial Tear Medication
Methylcellulose
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