Neurological Disorders

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NurseFaith
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261372
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Neurological Disorders
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2014-02-19 21:59:10
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Neurological Disorders NURS 304
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  1. Characteristics of Normal CSF
    • Pressure-          60-150 mm H20
    • WBC-               0-8 per ul
    • Protein-           14-45 mg/dl
    • Glucose-          45-75 mg/dl
    • Appearance-     Clear and colorless

    *if pink/red tinged --> sub-arachnoid hemorrhage 
  2. The most common infectious disorders of brain and spinal cord

    Commonly caused by bacteria, viruses, fungi, and chemical (ex. Contrast media)
    Meningitis
  3. Things meningitis is commonly caused by
    • Bacteria
    • Viruses
    • Fungi
    • Chemicals
  4. When assessing a patient for neuro disorders, assess....
    • ***Go into detail with symptom analysis
    • *CRANIAL NERVES/ Autonomic NS
    • Seizures?
    • Dizziness/vertigo?
    • Vision problems?
    • Muscle weakness?
    • Abnormal sensations?


    Assess: thought content, emotional status, cranial nerves, LOC, motor system, balance/coordination, reflexes, etc…
  5. Usually entry point for meningitis:
    • upper respiratory tract
  6. What type of precaution would a meningitis pt be on?
    Droplet Precautions
  7. What happens when there is a rupture of subarachnoid space?
    • Adhesions- (hydrocephalus)
    • Vasculitis- (stroke)
    • Encephalitus- (cerebral edema/increased ICP)
  8. If left untreated, bacterial meningitis has a ____ % rate of mortality
    100
  9. Which meningitis is considered a medical emergency?
    Bacterial (septic)
  10. Most common causes of Bacterial Meningitis:
    • Strep. pneumoniae
    • Meisseria meningitidis
  11. Which vaccine has helped with the bacterial meningitis?
    Hemophilus influenza
  12. Types of viruses that can cause Viral (aseptic) meningitis:
    Enteroviruses

    Arboviruses

    Human immunodeficiency virus (HIV)

    Herpes Simplex virus (HSV)
  13. Types of fungal agents that lead to meningitis:
    Candida albicans, Histoplasmosis capsulatum
  14. Bacterial Meningitis:
    •Inflammatory response, ↑CSF, ↑ICP

    •If the brain parenchyma involved → cerebral edema and further ↑ICP
  15. Organisms cross the __________ in Bacterial Meningitis, leading to inflammation
    Blood Brain Barrier
  16. Clinical Manifestations of Bacterial Meningitis:
    •Meningeal irritation

    • •Nuchal rigidity (stiff neck) --
    • Any attempts at flexion of the head are difficult because of spasms in the muscles of the neck. Usually, the neck is supple, and the patient can easily bend the head and neck forward.

    • Positive Kernig’s--
    • Patient is lying with the thigh flexed on the abdomen, the leg cannot be completely extended...When Kernig’s sign is bilateral, meningeal irritation is suspected 

    • *Brudzinski’s --
    • Patient’s neck is flexed (after ruling out cervical trauma or injury), flexion of the knees and hips is produced; when the lower extremity of one side is passively flexed, a similar movement is seen in the opposite extremity. Brudzinski’s sign is a more sensitive indicator of meningeal irritation than Kernig’s sign.

    •Photophobia (extreme sensitivity to light), fever, H/A, N/V, ↓LOC, ↑ICP

    •Meningococcus- rash, petechiae
  17. Septic Meningitis
    Bacterial Meningitis

    (Streptococcus pneumoniae and Neisseria meningitidis)
  18. Aseptic Meningitis
    • Viral Meningitis
    • (enteroviruses)
  19. N. meningitidis is more likely to occur in what type of population?
    Dense (college campuses, military installations)
  20. Factors that increase the risk of bacterial meningitis:
    Tobacco use and viral upper respiratory infection -- increase the amount of droplet production

    Otitis media and mastoiditis -- the bacteria can cross the epithelial membrane and enter the subarachnoid space.

    People with immune system deficiencies are also at greater risk for development of bacterial meningitis
  21. Major complications of bacterial meningitis:
    •Most common- ↑ICP

    •CN alterations

    •Noncommunicating hydrocephalusà caused by adhesions (scar tissue that blocks blood flow and pressure/fluid continues to build)

    •Waterhouse-Friderichsen syndrome/DICà disseminated intravascular coagulation (widespread hemorrhages)…patient will begin to bleed out of every place…SHOCK…patient will die

    ...visual impairment, deafness, seizures, paralysis, hydrocephalus, and septic shock.
  22. Initial symptoms of meningitis:
    H/A and Fever
  23. Meningitis in AIDS patients
    • •Cryptococcal meningitis is the most common fungal infection of the central nervous system in patients with AIDS. Patients may experience headache, nausea, vomiting, seizures, confusion, and lethargy. Treatment consists of IV administration of amphotericin B followed by fluconazole. Maintenance therapy with fluconazole may be necessary to prevent relapse.
    • • Some patients who are immunosuppressed develop few if any symptoms because of blunted inflammatory responses; others develop atypical features.
    • • Onset of fever, headache, nausea, and malaise most often occur over a few weeks. Only 25% of patients present with stiff neck and photophobia.
  24. Meningitis in Lyme disease patients
    • Lyme disease is a multisystem inflammatory process caused by the tick-transmitted spirochete Borrelia burgdorferi.
    • • Neurologic deficits are seen in later stages (stages 2 or 3). Stage 2 occurs with the start of a characteristic rash or 1–6 months after the rash has disappeared.
    • • Neurologic comorbidities include aseptic meningitis, chronic lymphocytic meningitis, and encephalitis.
    • • Cranial nerve inflammation, including Bell’s palsy and other peripheral neuropathies, is common.
    • • Stage 3 (the chronic form of the disease) begins years after the initial tick infection and is characterized by arthritis, skin lesions, and neurologic abnormalities.
    • • Most patients with stage 2 and 3 Lyme disease are treated with IV antibiotics, usually ceftriaxone or penicillin G.
    • • Meningeal and systemic symptoms begin to improve within days, although other symptoms, such as headache, may persist for weeks.
  25. In a patient with altered LOC, papilledema, neurologic deficits, new onset of seizure, immunocompromised state, or history of central nervous system (CNS) disease, these diagnostic tests are used to detect a shift in brain contents (which may lead to herniation) prior to a lumbar puncture (MENINGITIS)
    CT scan, MRI
  26. Diagnostic Tests for Bacterial Meningitis:
    • CT -- (assesses ICP and hydrocephalus)
    • MRI
    • Bacterial (nasal) culture and Gram-Staining of CSF-- (allows for rapid identification of the causative bacteria and initiation of appropriate antibiotic therapy)
    • X-ray- (may be able to trace back
    • to sinus infection)

  27. Risks for unfavorable outcomes for patients with bacterial meningitis:
    • Older age
    • HR > 120 bpm
    • Decreased Glasgow Coma Scale Score
    • Cranial nerve palsies
    • Positive Gram stain 1 hour after presentation to the hospital
  28. What is the first thing to be done when a patient presents to ER with symptoms of bacterial meningitis?
    • CULTURES!
    • (have done within 20 min of arrival, then start antibiotic therapy)
  29. Normal findings of CSF
    • WBC- 1000/ul
    • Protein- >500 mg/dL
    • Glucose- low < 45 mg/dL
    • Turbid color
    • (if pink/red  tinged -- indication of hemorrhage)
  30. What should be done before any Dx procedures for a patient suspected to have bacterial meningitis?
    Assess Pt. LOC and ability to handle procedures, look for papiledema, assess any neurodeficit, assess history of CNS disorders
  31. What are nursing interventions implemented on a patient with bacterial meningitis
    Medical emergency

    • Placed on respiratory isolation (any discharge is considered infectious)…droplet
    • precautions

    • MENINGOCOCCAL MENINGITIS IS
    • CONTAGIOUS- don’t take any risks…educate family!

    • Collect Cultures FIRST, then start antibiotics
    • (Most commonly prescribed- Penicillin G and Cephalosporins)

    Resolve infection

    •Control discomfort/Pain management

    •Decrease stimuli-- getting rest in dark, quiet room

    •Family at bedside/family education

    •Seizure precautions

    •Cooling blanket/Antipyretics for fevers

    •Fluids

    • •IVF
    • *Frequent neurological monitoring and vital signs


    Protecting the patient from injury secondary to seizure activity or altered LOC

    Monitoring daily body weight; serum electrolytes; and urine volume, specific gravity, and osmolality, especially if syndrome of inappropriate antidiuretic hormone (SIADH) is suspected


    Preventing complications associated with immobility, such as pressure ulcers and pneumonia
  32. Recommended Antibiotic Therapy for Bacterial meningitis:
  33. Medications used for treatment of Bacterial Meningitis:
    • COMMON: (given IV within 30 min of arrival)
    • Penicillin G
    • Cephalosporins

    • •Decadron- decreases inflammation
    • (Beneficial as adjunct therapy in the treatment of acute bacterial meningitis and in pneumococcal meningitis if it is administered 15 to 20 minutes before the first dose of antibiotic and every 6 hours for the next 4 days. Research suggests that dexamethasone improves the outcome in adults and does not increase the risk of gastrointestinal bleeding)

    • •Antipyretics-
    • (used for fever, ↑ cerebral edema, and seizures)

    •Analgesics

    •Antiseizure meds

    • •Diuretics- Mannitol-
    • (reduces cerebral edema)
  34. Convalescent Nursing Interventions for Bacterial Meningitis:
    **some patients will not go home right away depending on the severity of disease

    • •Nutrition
    • (High protein, high calorie foods in small, frequent feedings)

    • •Progressive ROM exercises and Warm Baths
    • (for muscle rigidity)

    •Gradual progression of activity

    •Adequate rest & sleep

    •Assessment of long term sequelae– (hearing, CN damage, seizures, long term med therapy, etc....

    Dementia, Seizures, Deafness, Hemiplegia, Hydrocephalus.  Should also assess vision, hearing, cognitive skills, and motor and sensory abilities. Infants may have silient sequelae that are not apparent until they start to school and have learning and behavioral problems)


    •Family support
  35. Key Health Promotion for Bacterial Meningitis
    Vaccinations: 2011 guidelines from CDC- youth 11-12yrs, booster at 16

    • People who have been in close contact with anyone who has bacterial meningitis should be treated with prophylactic antibiotics.
    • Rifampin (Rifadin), ciprofloxacin hydrochloride (Cipro), or ceftriaxone sodium (Rocephin).

    Early and vigorous treatment of resp. and ear infections is very important.

  36. Normal CSF pressure
    100-180
  37. Bacterial Meningitis CSF pressure
    200-500
  38. Viral Meningitis CSF pressure:
    <250
  39. Fungal Meningitis CSF pressure
    >200
  40. Normal WBC count in CSF
    0-5
  41. WBC count in CSF of Bacterial Meningitis
    100-5000
  42. WBC count in CSF of Viral Meningitis
    50-1000
  43. WBC count in CSF of Fungal Meningitis
    >20
  44. Dehydration and Shock is treated with
    fluid volume expanders
  45. Seizures are treated with
    Phenytoin
  46. If increasing ICP compromises the brain stem, the patient may need:
    • Respiratory Support
    • (Insertion of a cuffed endotracheal tube- or tracheotomy- and mechanical ventilation to maintain adequate tissue oxygenation)
  47. What is the main treatment plan for a patient with VIRAL (aseptic) meningitis
    • Treat Symptoms
    • Prevent increased Intracranial Pressure
  48. What lab finding is common in aseptic meningitis patients?
    • LP (lymphocytosis)
    • *NO organisms in culture!
  49. Herpes simplex virus 1 affects:
    Adults and Children
  50. Herpes simplex virus 2 affects:
    Neonates
  51. Acute inflammatory process of the brain tissue...Herpes simplex virus is the most common cause
    Encephalitis
  52. Clinical Manifestations of Encephalitis (caused by HSV1)
    Fever, Headache, Confusion, and Hallucinations. Focal neurologic symptoms reflect the areas of cerebral inflammation and necrosis and include fever, headachebehavioral changes, focal seizures, dysphasia, hemiparesis, and altered LOC
  53. Diagnostic Tests for Encephalitis
    • Lumbar Puncture (CSF)
    • CT
    • MRI
    • EEG
    • CAT scan
    • Brain imaging
    •   PCRà specific DNA/RNA
    • (standard test for early diagnosis of HSV 1 encephalitis. PCR identifies the deoxyribonucleic acid (DNA) bands of HSV-1 in the CSF. The validity of PCR is very high between the 3rd and 10th days after symptom onset)
  54. Management of Encephalitis:
    •Mosquito Program

    •HSV- most severe form of viral encephalitis; Zovirax, Vira-A

    •Seizures- antiseizure meds

    •Cerebral edema- Mannitol and Decadron

    ***Antiviral agents, either acyclovir (Zovirax) or ganciclovir (Cytovene), are the medications of choice in the treatment for HSV. Early administration of antiviral agents (usually well tolerated) improves the prognosis associated with HSV-1 encephalitis

    •Antimicrobial therapy- corticosteroids to decrease pressure

    •I&D

    •Management of sx- providing comfort
  55. What are some ways that the nurse can help reduce headache
    dimming the lights, limiting noise and visitors, grouping nursing interventions, and administering analgesic agents.
  56. ___________ management is key for arboviral encephalitis patients
    Symptom
  57. Public education addressing the prevention of arboviral encephalitis
    Clothing that provides coverage and insect repellents containing 25% to 30% diethyltoluamide (DEET) should be used on exposed clothing and skin in high-risk areas to decrease mosquito and tick bites. Remaining indoors at dawn and dusk when mosquito activity is highest is recommended. Screens should be in good repair in the home, and standing water should be removed. All cases of arboviral encephalitis must be reported to the local health department
  58. Human variation of bovine spongiform encephalopathy (commonly known as mad cow disease)
    Creutfeldt-Jakob Disease (CJD) and Variant Creutzfeldt-Jakob Disease (vCJD)

    (results from the ingestion by humans of prions in infected meat)
  59. Clinically Manifestations of CJD and vCJD
    behavioral changes, sensory disturbance, and limb pain, Muscle spasms and rigidity, dysarthrias incoordination, cognitive impairment, and sleep disturbances follow. Patients with sporadic CJD present with mental deterioration, ataxia, and visual disturbance. Memory loss, involuntary movement, paralysis, and mutism occur as the disease progresses
  60. An accumulation of pus within the brain resulting from a local or systemic infection (may be related to ear, tooth, or sinus infection or pulmonary infection or bacterial endocarditis)

    Primary organisms are streptococci or Staphylococcus aureus
    Brain Abscess
  61. Clinical Manifestations of Brain Abscess
    • Similar to meningitis and encephalitis-
    • H/A, fever, N/V, ↑ ICP, focal sx
  62. Dx Test for Brain Abscess
    CT and MRI
  63. Loss of ability to recognize objects through a particular sensory system; may be visual, auditory, or tactile
    Agnosia
  64. Weakening or bulge in an arterial wall
    Aneurysm
  65. Inability to express oneself or to understand language
    Aphasia
  66. Inability to perform previously learned purposeful motor acts on a voluntary basis
    Apraxia
  67. difficulty swallowing
    Dysphagia
  68. Inability to express oneself; often associated with damage to the left frontal lobe area
    Expressive Aphasia
  69. Decadron is given (for bacterial meningitis) within _____ after antibiotics are started:
    15-20 minutes
  70. Assessing for Brain Abscess
    • Be alert to the following signs and symptoms of brain abscess:
    • Frontal Lobe
    • Hemiparesis (weakness on one side of the body) Expressive aphasia (inability to express oneself) Seizures, Frontal headache
    • Temporal Lobe
    • Localized headache, Changes in vision, Facial weakness, Receptive aphasia (inability to understand language)
    • Cerebellar 
    • Occipital headache, Ataxia (inability to coordinate movements) Nystagmus (rhythmic, involuntary movements of the eye)
  71. Treatment for Brain Abscess focuses on:
    controlling increased ICP, draining the abscess, and providing antimicrobial therapy directed at the abscess and the main source of infection
  72. Large IV antibiotic treatment for Brain Abscess is usually based on the culture results. However, antibiotics need to be started as soon as possible so the initial antibiotic that is started is usually:
    Ceftriaxone, which will be adjusted based on the culture and sensitivity results
  73. Medications used for Brain Abscesses:
    • Antibiotics (ceftriaxone)
    • Corticosteroids
    • Anti-seizure
  74. Blood laboratory test results, specifically________ , need to be closely monitored when corticosteroids are prescribed
    • blood glucose and serum potassium levels
    • Normal Glucose= 70-100
    • Potassium- 3.5-5.5
  75. Generalized Seizures move across ______
    Both Hemispheres of the brain
  76. Spontaneous recurring seizures
    Epilepsy
  77. Types of Generalized Seizures
    • Tonic-Clonic
    • Absence Seizures
    • Myoclonic Seizure
    • Atonic Seizure
  78. Type of seizure in which a pt may have an aura, may exhibit unusual behavior, may have post ictal stage with confusion (similar to petit-mal)
    Atypical Absence
  79. Type of seizure in which pt can be thrown to floor with explosive jerking
    Myoclonic
  80. Drop Attack seizure
    Atonic
  81. Greatest risk for myoclonic and atonic seizure patients
    head injury!
  82. Partial seizures last:
    < 1 min
  83. Phases of a seizure
    • Prodromal- activity that precedes a seizure
    • Aura- sensory warning of seizure
    • Ictal- Full seizure state
    • Post-Ictal- period of recovery after seizure
  84. Nursing role after a patient has a seizure
    Assess Breathing
  85. Clinical manifestations of tonic stage
    apnea (10-20 sec), muscle stiffening
  86. Clinical Manifestations of Clonic Stage
    • Contraction and Relaxation (jerking 30-40 sec)
    • Cyanosis
    • Increases Saliva
    • Biting
    • Incontinence
  87. Clinical manifestations of Post-Ictal state
    No memory of Seizure
  88. Clinical Manifestations of Partial Seizures
    motor and sensory
  89. Complex partial seizures usually occur in:
    Temporal Lobe
  90. Lip smacking, licking lips, picking at clothes...
    Automatisms (occur with complex partial seizure)
  91. Dx studies of Seizures
    • Detailed Health History (helps if family is present to give detailed info in what happens when the pt has a seizure)
    • EEG (electroencephalogram) -- electrical activity of brain waves
    • Serum Lab Studies
  92. Patient Prep for EEG
    • Teach pt that the test is painless
    • No electrical shocks are given
    • Avoid caffeine and stimulants
    • Determine if antiseizure drugs or tranquilizing meds need to be held prior to test
  93. Post EEG care of seizure patient
    Resume all meds after test

    Assist pt to wash electrode gel out of hair
  94. It is best to perform EEG within _____ hours of seizure
    24
  95. Lab tests that can be done to help rule out metabolic disorders that cause seizures
    CBC, Liver and Renal function, Urinalysis
  96. Tests done to rule out structural lesions (tumors) as a cause for seizures
    CT or MRI
  97. Continuous seizures when the energy demand is greater than the body's supply
    Status epilepticus
  98. Nursing priority for status epilepticus patient
    STOP SEIZURES!!!
  99. Main complication of Status Epilepticus
    Brain Damage
  100. Patient Education for Status Epilepticus pts once they have been diagnosed
    NO driving
  101. Medications used to stop seizures immediately for status epilepticus
    • IV Valium
    • IV Ativan
  102. Side Effects of Drug therapy in seizure patients
    • Nystagmus
    • Drowsiness,
    • Rash,
    • Slowness,
    • Liver/Kidney Disorders,
    • Bone Marrow Depression
  103. Therapeutic Drug Range for Dilantin (phenytoin)
    10-20
  104. Pt education regarding Dilantin
    Pt will need to have lab work done regularly to monitor levels for therapeutic range

    ORAL CARE (gingival hyperplasia)
  105. ____ is sometimes used instead of Dilantin in the elderly population
    Kepra
  106. Antiseizure meds:
    • Tegretol
    • skin rash, blood dyscrasias, hepatitis

    • Klonopin-
    • Hepatotoxicity, thrombocytopenia, bone marrow failure, ataxia

    • Zarontin
    • Skin rash, blood dyscrasias, hepatitis, systemic lupus erythematosus

    • Felbatol
    • Aplastic anemia, hepatotoxicity

    • Neurontin
    • Leukopenia, hepatotoxicity

    • Lamictal
    • Severe rash (Stevens-Johnson syndrome)

    Keppra

    • Trileptal
    • Hepatotoxicity

    • Luminal
    • Skin rash, anemia

    • Dilantin
    • Gingival Hyperplasia, 

    • Mysoline
    • Rash

    Gabitril

    • Topamax
    • Nephrolithiasis

    • Depakote
    • Hepatotoxicity, skin rash, blood dyscrasias, nephritis

    • Zonegran
    • Leukopenia, hepatotoxicity
  107. Surgical Interventions for Seizures
    • Foci Removal
    • Vagal Nerve Stimulation -- interrupts the neurons firing that would normally cause the abnormal brain activity

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