stroke,cns problems, pns problems PART I

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agnosia

inability to determine meaning of stimuli

aphasia

loss of language faculty

ataxia

lack of movement coordination

lumbar puncture

1. pt empty bladder
2, recumberent position
3. strict sterile techinque
4. MUST lay flat for a few hours after procedure
5.NURSE WILL LOOK FOR S/S of headache and look for CSF leakage

dysarthia

poor speech articulation

dyskinesis

impaired voluntary movement

dysphagia

difficult swallowing

hemiplegia

paralysis on one side

nystagmus

jerking of eyes as they track moving object

paraesthesia

weakness on one side

tretaplegia

quadriplegia
paralysis of all extemities

diagnositc studies for neuro problems

cerebrospinal fluid analysis
radiologic studies of skull and spine(cerebral angiography,CT scan,NRI, myelography
EEG

stroke risk

age,geneder,race , heredity
HYPERTENSION (for hemmorrhagic stroke***)
artheroscelrosis( for ischemic stroke)
anticoagulant theraphy( hemmorrhagicO
uncontrolled DBM
obesity
oral contraceptives

ischemic stroke

stroke that results from inadequate blood flow to the brain caused by partial or complete occlusion of an artery.

pathophysiology of a hemmorrhagic stroke

bleeding in the brain, blood vessel is broke r/t aneurysm, malformation or hypertension

embolic stroke

Fragments that break from a thrombus formed outside the brain

clinical manifestation of a stroke

COGINITIVE CHANGES_change-altered LOC,impaired memory,judgement or problem-solving, decreased ability to concentrate and focus
MOTOR CHANGES- hemiplegia, hemiparesis
SENSORY CHANGES-diminished response to touch, or painful stimuli
****expressive aphasia-inability to speak correctly-nurse should ask simple yes or no questions
inability to use an object correctly
hemianopais -blindness in 1/2 of visin
CARDIO
heart dysrhythmias, hypertension

diagnsostic studies for stroke

check h and h will show increase as body attempts to compensate for lack of oxygen
coagualtion test are orderes
CT so can differentiate hemmorrhage vs ischemic ***
MRI will indicate edema, ischemia,tissue necrosis

NURSING CARE DURING AN ACUTE STROKE

Ensure patent airway - may need to suction!****
Call stroke code or stroke team - monitor VS
Remove dentures in case of seizure
Perform pulse ox, maintain O2 levels
Establish IV access - maintain F&E balance
Maintain BP - IV antihypertensives ***
Remove clothing, quiet room, dim lights
Obtain CT scan immediately to determine if bleeding
Perform labs
Elevate HOB 30 ° if no s/s shock
NPO until gag reflex returns ( swallowing evaluation) *****
Drugs: (stool softners, pain, antianxiety meds)
TPA - thromboembolytic
Coumadin and ASA
DO NOT GIVE thromboembolytics/anticoagulants if s/s hemorrhagic stroke (ie., - HEADACHE)*****

NURSE CARE AFTER A STROKE

Reposition q 2 hours - prevent decubitus ( ulcer)
Skin, oral, eye care
Passive ROM to prevent contractures
TED hose to prevent DVT's
Monitor gag reflex and ability to swallow - provide thickened liquids if needed.*****
Have patient sit upright to eat.
Place food on unaffected side - encourage to feed self with unaffected hand
Teach to touch and use both sides of body
Place objects within visual field
Mobility as tolerated - physical and occupational therapy
Encourage independence and to express feelings
Ask only simple questions if communication problems

Transient Ischemic Attack

Brief interruption of cerebral blood flow
s/s brief dizziness, tinnitus, diplopia
Due to HTN or
Partially blocked carotid artery
After a TIA, patient is started on ASA, Plavix or Ticlid - to prevent stroke*****

types of seizures

Tonic - abrupt muscle tone, loss of consciousness
Clonic - muscle contraction and relaxation
Tonic-Clonic (most common generalized)
Absence - brief periods of loss of consciousness and blank staring as though person is daydreaming
Myoclonic - brief jerking of extremities
Atonic - sudden loss of muscle tone

treatment antieplictic drugs

Meds - Antiepileptic Drugs - Table 59-9
Generally act by stabilizing nerve cell membranes and preventing spread of the epileptic discharge.
**Primary goal of antiseizure drugs is to obtain maximum seizure control with minimum amount of toxic side effects.
**Begin with single drug - loading dose (larger than usual dose) to bring blood to therapeutic level.
**Serum drug levels monitored for therapeutic range.
Seizures may be controlled with less than therapeutic level of med or greater than therapeutic level (if no side effects)
May need combination regimen

treatment for seizure

Meds - Antiepileptic Drugs - Table 59-9
Client and Family Education - Table 59-12
Seizure Emergency Management - Table 59-8
Injury Prevention
Turn head to side to prevent aspiration
Do not restrain
Sometimes oxygen is given
Surgery
Vagal Nerve Stimulation
Resection of brain area in which seizures originate

dilantin

Take as prescribed
Take with food but avoid milk
Do NOT discontinue ABRUBTLY - may cause status epilepticus!****
Maintain good oral hygiene and use soft toothbrush
Have blood drawn for drug levels
May cause liver damage - avoid alcohol and do not take if you've had liver disease
Do NOT change brands of DILANTIN to generic without first checking with MD.

seizure precaution

During a seizure, a person may injure himself or herself.
Nurse needs to assess for injury after seizure****
Seizure precautions are guidelines that a person can follow in order to minimize injury during a seizure. For any activity, it is important to ask, "What would happen if I had a seizure while doing this?"
Remove potentially harmful objects from environment
Keep suction device and airway at bedside
Padded side rails to prevent injury

surgery mangement for a stroke

Endarterectomy
Remove atherosclerotic plaque from inner lining of the carotid artery.**
Extracranial-intracranial bypass
Craniotomy and bypass the blocked artery by making a graft from the first artery to the second artery. Blood flow is established around the blockage.***

Drugs for TIA

asprin beginning dose of 81 mg and up to 325 mg since it is an antiplatelet

ticlopidine(Ticlid) antiplatelet but S/E- Neutropenia/thrombocytopenia,

clopidogrel (Plavix)- diminished efffectiveness with poor metabolizer, PPI lower effectveness advised 12 hours apart

manifestation of parkinson

T Tremor Involuntary trembling of the limbs - hands, fingers
R Rigidity Stiffness of the muscles
A Akinesia Lack of movement or slowness in initiating and maintaining movement
P Postural instability
Characteristic bending or flexion of the body, associated with difficulty in balance and disturbances in gait

stages of parkinson

Initial
1.Unilateral limb involvement
Minimal weakness
Hand and arm trembling
2 Mild Stage
Bilateral limb involvement
Masklike face
Slow shuffling gait
3Moderate Disease
Increased gait disturbances
4,Severe Disability and Rigidity
5 Complete Dependence - mental deterioration

non- surgical of parkinson

Meds - Table 59-18
Anticholinergics
Dopamine Agonists - stimulate dopamine
Levodopa - contra-indicated in glaucoma!
Catechol inhibitors - block enzymes that inhibit dopamine
Exercise - yoga, tai-chai
Nutrition - may need 'thick-it'
Speech Therapy

intervention of parkinson

Assess neuro status, ability to swallow and chew
High-calorie, high-protein, high-fiber diet
Fluid intake at least 2000 mL / day
Monitor for constipation
Avoid rushing with activities - assistive devices as needed
Instruct to rock back and forth to initiate movement
Low-heeled shoes
Encourage to lift feet when walking
Firm mattress - facilitate proper posture

surgical mgmt of parkinson

Used as last resort when drugs no longer effective
Deep Brain Stimulation - delivers current to the targeted brain location to control symptoms.
Transplantation of fetal neural tissue into basal ganglia - experimental stages

huntington disease

Genetic disorder transmitted as an autosomal dominant trait at the time of conception
Rare - Affects ~ 30,000 in U.S.
S/S begin between 35 - 50 years of age
Neurons of the cerebral cortex are destroyed

huntington disease s/s

Progressive mental status changes, leading to dementia
Choreiform Movements - rapid, jerky movements in the limbs, trunk and facial muscles *

management of huntingtons disease

No known cure or treatment
Genetic counseling important
Care is managed collaboratively:
Speech therapy for communication/swallowing
Dietician for meal plans
O.T. and P.T.
Social Worker to assist with referrals
RN/Home Health Aide for direct care/assessment

Multiple Sclerosis

A chronic autoimmune disease that causes inflammation and destruction in the myelin sheath and conduction pathway of the CNS.
Myelin is responsible for the electro-chemical transmission of impulses between the brain and spinal cord and the rest of the body.
Impulses are still transmitted but not as effective as before.

clinical manifestation of mutiple sclerosis

Muscle weakness and spasticity
Fatigue
Tremors and spasticity of lower extremities
Parasthesia - Numbness or tingling
Ataxia - decreased muscle coordination
Dysarthria - slurred speech
Scotomas - vision changes, blurry, double
Tinnitus - ringing in the ears
Cognitive changes - memory loss, impaired judgment, decreased problem-solving ability
Emotional changes - irritability, depression

MS treatment

Biological Response Modifiers
Immunosuppressive Therapy
Steroid Therapy
Antispasmodic Therapy
Symptom Management

INTERVENTION
Provide energy conservation
Protect from injury
Monitor for UTI
Encourage independence
Encourage regular exercise and rest
Assistive devices as needed
PT, OT, ST as needed
Avoid fatigue, stress, infection, overheating and chilling

The nurse determines that baclofen (Lioresal) is accomplishing its intended purpose for a client with MS when it achieves which of the following?

relieves muscular spasticity

intervention should the nurse suggest to help a client with MS avoid episodes of urinary incontinence?

Establish a regular voiding schedule.

ALS Mgmt

Goal - symptom control.
Meds to control spasticity that interferes with ADL's.
Physical therapy, rehabilitation, braces, wheelchair, or other orthopedic measures may be needed to maximize muscle function and general health.
Choking is common. Tube Feedings.
Focus care on respiratory maintenance. The use of devices to assist in breathing includes machines that are only used at night as well as mechanical ventilation. Patients should discuss their wishes regarding artificial ventilation with their doctors.

Myasthenia Gravis

Chronic disease characterized by fatigue and weakness primarily in muscles innervated by the cranial nerves as well as in skeletal and respiratory muscles.
Progressive autoimmune disease of the neuromuscular junction
Caused by an autoantibody attack on the acetylcholine receptors in the muscle end plate membranes.
Nerve impulses are not transmitted to the skeletal muscle at the neuromuscular junction.

clinical manifestation of Myasthenia Gravis

Progressive muscle weakness, improves with rest
Poor posture
Ptosis, diplopia
Incomplete eye closure
Respiratory complications:  breath sounds
Loss of bowel and bladder control
Fatigue
Difficulty chewing, swallowing
Decreased smell and taste
Respiratory paralysis and failure

treatment of Myasthenia Gravis

Meds
Anticholinesterases
Enhance neuromuscular impulse transmission
Improve muscle strength
Immunosuppresants & Corticosteroids
Suppress immune response
Plasmapheresis
short-term improvement

Periphereal nerve problems

Guillain-Barre syndrome
Botulism
Tetanus
Trigeminal Neuralgia -fifth cranial nerve
Bell's Palsy-7yh cranial nerve

Guillain-Barre syndrome

Acute autoimmune disorder
Characterized by varying degrees of motor weakness and paralysis -
Complication is respiratory failure
The immune system starts to destroy the myelin sheath that surrounds the axons between the nodes of Ranvier.
The result is dispersion of impulses and slow conduction.

difference between Guillian syndrome and MS

is that multiple sclerosis attacks the central nervous system, whereas in the Guillain-Barre syndrome, it is the peripheral nerves that are affected. The nerve damage is thought to be the result of an abnormal immune reaction directed against the myelin of the peripheral nervous system. Another difference is that Guillain-Barre syndrome does not recur except in rare instances.

treatment of Guillian-Barre

Priority intervention is to maintain adequate respiratory function
Nutritional support - d/t weakness
May need foley - d/t urinary retention
Plasmapheresis
Removes the circulating antibodies thought to be responsible for the disease.
Plasma is selectively separated from whole blood - 3 or 4 treatments, 1-2 days apart

boutilism

Most serious type of food poisoning.
Clostridium botulinum causes paralysis and death can occur within 24 hours.
Spores are found in soil and can spread through air or food (improperly canned food) or via a contaminated wound
Cannot be spread from person to person

manifestation of boutilism

Abdominal cramps
Diarrhea
N/V
Diploplia
Blurred vision
Difficulty swallowing or speaking
Dry mouth
Muscle weakness
Progressive paralysis to arms, legs, trunk, respiratory muscles

treatment of boutlism

Antitoxin that blocks action of toxin circulating in the blood
Induced vomiting
enemas
penicillin
No vaccine is available

Tetanus

Severe infection of spinal and cranial nerves
Clostridium tetani - interferes with reflex functions
Spores are present in soil and manure.
Incubation period 3 - 21 days

manifestation of tetanus

Stiffness in jaw and neck
Fever
Generalized spasms
Progressive rigidity of neck, back, abdomen and extremities.
Respiratory spasms cause apnea and anoxia
Seizures
Death

interventions for tetanus

Goal - ensuring tetanus prophylaxis
Immunization - booster q 10 years
Clean wounds with soap and water

Trigeminal Neuralgia

Affects the fifth cranial nerve (trigeminal nerve)
Unilateral facial pain which occurs in abrupt, intense spasms
Very painful, sharp electric-like spasms last a few seconds to minutes
Pain is triggered by touch or sounds
Pain during chewing, eating, drinking, shaving, or brushing teeth

Bouts of pain are followed by periods of remission

treatment for neuralgia

Certain Anti-epilepsy drugs (lengthen time needed for neuron firing) Tegretol
Migraine medicines (sumatriptan)
Tricyclic antidepressants such as amitriptyline, nortriptyline, or carbamazepine

Bells palsy

Bell's palsy is a temporary form of facial paralysis. It results from lesion or damage to the nerve that controls movement of the muscles in the face.
Bell's palsy involves damage to the seventh cranial (facial) nerve. This nerve controls the movement of the muscles of the face. The cause is often not clear, although herpes infections may be involved.
Bell's palsy is thought to be linked to inflammation of the nerve in the area where it travels through the bones of the skull.

symptoms of bells palsy

Symptoms usually start suddenly, and range from mild to severe. They may include:
Twitching in face
Weakness in face
Face feels stiff or pulled to one side
Droopy eyelid or corner of mouth
Drooling due to inability to control facial muscles
Paralysis of one side of the face, makes it hard to close one eye
Change in facial expression (for example, grimacing)
Dry eye or mouth
Loss of sense of taste.
Difficulty with eating and drinking
Pain behind or in front of the ear, may occur 1-2 days before muscle weakness
Sensitivity to sound (hyperacusis) on the side of the face affected
Headache

treatment of Bells Palsy

In many cases, no treatment is necessary. The goal of treatment is to relieve the symptoms. Recovery usually occurs within a few weeks, without residual effects.
Corticosteroids or antiviral medications may reduce swelling and relieve pressure on the facial nerve. These drugs must be given early to be most effective (preferably within 24 hours of the symptoms starting).
Lubricating e
ye drops or eye ointments
Frequent oral care
Chew on unaffected side
Surgery to relieve pressure on the nerve (decompression surgery) is controversial and has not been shown to routinely benefit people with Bell's palsy

Acetaminophen

- relieves pain & fever - don't exceed 4 g daily

Clopidogrel - Plavix

- diminished effectiveness w/ poor metabolizer, PPI lower effectiveness advised 12 hrs apart

Streptokinase - Streptase

Management of acute, sever pulmonary emboli or iliofemoral thrombophlebitis - dissolves clots - Throbolytic agent - break down fibrin

Diphenhydramine - Benadryl

- used in allergic reactions, motion sickness, Parkinson's, Insomnia, Antitussive S/E drowsiness and anticholinergic effects

Tissue plasminogen activator

- administer IV with in 3-4.5 hours of signs of ischemic stroke. Must be screened with CT or MRI to rule out hemorrhagic stroke, blood tests for coagulation disorders and GI bleed, stoke or head trauma within last 3 months or major sx in 14 days.

Ticlopidine - Ticlid

anti-platelet, S/E Neutropenia/thrombocytopenia

Asprin

dose 81 mg to 325 mg - relieve pain, fever, inflammation - S/E stomach upset, GI bleed, MI & Stroke prevention,

Divalproex

Antiseizure drugs - used for absence, mixed and complex partial seizures

Mydriatic agents

dialates pupil, an a-adrenergic agonist - teach to wear dark glasses to minimize photophobia, monitor for signs of systemic toxicity (inc B/P, tachycardia)

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