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Acute Care Exam 3 > CH 46&47: Neurological Disorders > Flashcards

CH 46&47: Neurological Disorders Flashcards

1
Q

what is meningitis

A

Inflammation of the meninges
– Protective membranes that cover the brain and spinal cord

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2
Q

causes of meningitis

A

Bacterial & Viral (Most Common)
Fungi & parasites (Less Common)

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3
Q

pathogens of bacterial meningitis

A

streptococcus pneumoniae*
neisseria meningitidis (Primarily occurs in dense community groups)
–Ex: College campuses or military installations
Haemophilus influenzae
– Rare cause of bacterial meningitis because it is now a standard childhood vaccine (HIB vaccine)
– Watch for in non-vaccinated individuals

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4
Q

whos at risk for bacterial meningitis

A

Tobacco use
Viral URIs
Otitis Media
Mastoiditis - jaw
Immunosupressed
Under 2 months old
Elderly

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5
Q

direct spread of bacterial meningitis

A

Trauma injury to the facial bones
Skull or spine infection
Secondary to surgical procedures
Sinusitis, otitis, brain/spinal abscesses
Secondary to invasive procedures

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6
Q

isolation for contagious meningitis pathogen

A

isolation precautions (e.g., droplet)

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7
Q

patho of bacterial meningitis

A

Introduced  host immune response  cell breakdown  inflammatory response in the meninges  neutrophil response  CSF thickens
Thick CSF = poor absorption  Hydrocephalus
Increased ICP

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8
Q

CSF collection for meningitis will show:

A

lumbar puncture

decreased glucose
increased protein
increased WBC

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9
Q

clinical manifestations of bacterial meningitis**

A

Headache & Fever = Initial Symptoms
Altered level of consciousness / Disorientation
Nuchal Rigidity (stiff neck) = Early Sign
–Any attempts of flexion of the neck are difficult due to spasms in the muscles of the neck
Positive Kernig Sign
–Lying the patient in the supine position with the hip flexed at a 90-degree angle, resistance is met during passive extension of the knee
Positive Brudzinski Sign
–When the patient’s neck is flexed, flexion of the knees and hips are produced
Photophobia (sensitivity to light)
Rash
–Seen in patients infected with the Neisseria Meningitidis
–Petechial rash with purpuric lesions to large areas of ecchymosis
Possible seizure activity - 40-50%**

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10
Q

Bacterial Meningitis: Diagnostics

A

Diagnostics: Bacterial culture and gram stain of CSF (via lumbar puncture), and blood (venipuncture)
–No antibiotics until these are done!
–Gold Standard for definitive diagnosis
Head or spinal CT for abscess or lesion detection

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11
Q

abx for Bacterial Meningitis

A

Earlier the antibiotics = better outcomes
– Penicillins, cephalosporins, vancomycin (+ rifampin); All given IV
Note on blood cultures: 24-72 hours before results so can’t wait that long = empiric therapy will be started before results

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12
Q

Bacterial Meningitis: Nurse Management

A

Draw blood cultures first!!
IV fluids and abx for treatment
Seizure precautions (medications and seizure pads and oxygen)**
Watch for increased ICP and report to provider
Frequent neuro assessments
ABG’s, I&Os, DW, electrolytes
May need to be on a ventilator

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13
Q

dexamethasone purpose

A

steroid given to decrease inflammation

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14
Q

most common types of viral meningitis

A

Acute Aseptic Meningitis OR Acute benign lymphocytic meningitis
Most common of all types!

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15
Q

pathogens for viral meningitis

A

Enteroviruses (e.g., coxsackievirus, poliovirus, echovirus)
Found in immunocompromised (e.g., HIV) and in children

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16
Q

Viral Meningitis: Manifestation & Assessment

A

Headache, low-grade fever, nuchal rigidity, photophobia, malaise, viral URI symptoms
Does not usually have altered mental status and seizure activity
CT scan for signs of increased ICP
Lumbar puncture (clear CSF, not cloudy)
CSF: Increased protein and WBC but normal glucose and no bacteria

These patients do not normally have AMS and seizure

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17
Q

Viral Meningitis: Nurse Management

A

Less mortality with viral (Recovery in about 10 days)
Supportive care
Vomiting and pain management
Elevate HOB to at least 30 degrees with neutral head alignment
Dark quiet environment
Fever management
I&O’s

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18
Q

Nursing Assistance for a Lumbar Puncture

A

Informed consent
Patient Education
– Aseptic procedure carried out by inserting a needle into the lumbar subarachnoid space to withdraw CSF
– Patient must also void prior to procedure
Assist provider with patient positioning
– Patient positioned on one side (knee to chest position)
Medications pre/post procedure
Post-procedure Management

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19
Q

Encephalitis

A

Acute inflammation of brain tissue
Caused by bacteria, viruses, fungi, parasites
Viral most common (HSV 1 & 2)
– HSV-1 Children/adults
– HSV-2 Neonates through vaginal delivery

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20
Q

Encephalitis: HSV-1 Patho

A

Retrograde intraneuronal path
– Through the olfactory (smell) or trigeminal (facial movement) cranial nerves
Latent virus in brain tissue may reactivate
Cerebral edema and petechial hemorrhages  neuron damage
Initial symptoms are similar to meningitis:
– Fever, headache, nuchal rigidity, and confusion

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21
Q

Encephalitis: HSV-1 Manifestations

A

Focal neuro symptoms based on area inflamed
Behavior changes, seizures, dysphasia, hemiparesis, altered LOC, auditory/visual hallucination

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22
Q

Encephalitis: HSV-1 Diagnostics

A

Diagnostics: EEG, CT/MRI, CSF examination
Polymerase Chain Reaction (PCR) is the standard test for early diagnosis of HSV-1 Encephalitis; High validity of PCR between 3-10 days after onset of symptoms

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23
Q

Encephalitis: HSV-1 Management

A

Meds: Acyclovir (Zovirax)** is the antiviral agent of choice - 60-70% down to 30%
– Early admin improves prognosis!
Treat for 3 weeks
Slow IV rate (over 1-hour) + fluids to help prevent crystallization of the medication in the renal tubules
Assess neuro and kidney* function (labs + I&Os)
Comfort measures: Dimming the lights, limiting noise, and administering analgesics
Seizure precautions

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24
Q

Encephalitis: Arboviral West Nile Virus & St. Louis Arbovirus

A

West Nile Virus & St. Louis Arbovirus
Patho: Mosquito gets it from bird  bites human  viral replication in human  if survives, gets to cerebral capillaries
Spreads among neurons, affecting cortical gray matter, the brainstem & thalamus  irritates the meninges and increases ICP

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25
Encephalitis: Manifestations
Flu-like symptoms Neurological symptoms depend on area affected St. Louis type develops SIADH with hyponatremia (25-35%) West Nile has maculopapular or morbilliform rash (erythematous red rash resembling the measles) on neck, trunk, arms, legs; Flaccid paralysis Both West Nile and St. Louis encephalitis can lead to inflammation of the basal ganglia, which can result in parkinsonian-like movements
26
Encephalitis: Assessment
MRI and CSF evaluation for diagnosis -- Positive Diagnosis  Inform the health department, who will inform the CDC
27
Encephalitis: Management
No specific medication for treatment Supportive care Seizure precautions Neuro checks Prevention is key! Use insect repellent and rid areas of standing water
28
Stroke: Types
Interrupted blood flow to brain Ischemic (85%) : TIA Hemorrhagic (15%)
29
BE FAST recognition of stroke
Balance Eyes: blurred vision Face drooping Arms and legs weakness Speech difficulty Time to call for ambulance
30
cause of ischemic stroke
large-artery thrombosis small, penetrating artery thrombosis cardiogenic embolic crytopgenic (no known cause)
31
causes of hemorrhagic stroke
intracerebral hemorrhage subarachmoid hemorrhage cerebral aneurysm ateriovenous malformation
32
main presenting symptoms of ischemic stroke
numbness or weakness of the face, arm or leg, especially on one side of body
33
main presenting symptoms of hemorrhagic stroke
"exploding headache" decreased LOC
34
what is an ischemic stroke
Disruption of blood flow in or to the brain due to an obstruction of a blood vessel initiates a series of circulatory and metabolic events called the Ischemic Cascade, which leads to neuron and cell death.
35
types of ischemic strokes
Large-Artery Thrombotic Strokes - plaque Small Penetrating Artery Thrombotic Strokes - brain stem, cerebellum, thalamus, diabetes Cardio Embolic Strokes - heart pumps our clot - from afib Cryptogenic Strokes - no known cause
36
possible early treatment options
Thrombolysis (IV Thrombolytics) Clot Retrieval
37
Transient Ischemic Attacks (TIA)
Falls under Ischemic Strokes “Mini-Stroke” Symptoms last less than 24 hours No evidence of infarction of tissue on CT “Warning Strokes” Prevent further strokes
38
patho fo hemorrhagic strokes
Brain bleed (80% from uncontrolled HTN) Compresses brain tissue  increased ICP, Secondary hemorrhage  Worse ischemia  Possible herniation or hydrocephalus Coma or death if severe Intracerebral Hemorrhage (ICH) vs. Subarachnoid Hemorrhage (SAH between brain and protective membrane)
39
Arteriovenous Malformations (AVMs)
Common cause of strokes in younger patients During embryonic development, tangles of arteries and veins in the brain develop without a transitional capillary bed -- Increased pressure in those vessels  can lead to rupture
40
Dilated wall of an artery in the brain
aneurysms
41
causes of aneurysms
Atherosclerosis, Congenital defect of the vessel wall, hypertensive vascular disease, head trauma, advancing age
42
most common arteries affected by an aneurysm
Internal Cerebral Artery (ICA), Middle Cerebral Artery (MCA), and vessels near the Circle of Willis
43
Stroke: Risk Factors
Stroke belt - Southeastern U.S. Affects all ages but older men more than others Heart disease and Strokes go hand-in-hand Modifiable - hypertension, smoking, diabetes, dyslipidemia, atrial fibrillation, diet, obesity, heavy alcohol use, sleep apnea, sedentary lifestyle, lack of exercise Non-modifiable - age, race, gender, ethnicity, strong family history of stroke
44
Stroke: 7 D’s
Detection, Dispatch, Delivery, Door, Data, Decision, Drug Administration
45
Certified Stroke Centers Must have
Acute stroke team, stroke unit, care protocols, supporting lab and imaging services, and mandatory continuing education related to strokes
46
Stroke: Assessment left hemispheric stroke
paralysis or weakness on right side right visual field deficit aphasia altered intelectual ability slow, cautious behavior math difficulty
47
stroke assessment for right hemispheric stroke
paralysis or weakness on left side left visual field deficit spatial-perceptual deficits ** distance increased distractibility impulsive behavior and poor judgement lack of awareness of deficits
48
National Institutes of Health Stroke Scale (NIHSS)
1a/b/c LOC 2. Best gaze 3. Visual - fingers holding up looking at my nose 4. Facial Palsy - smile, raise eyebrows 5a/b – Motor L/R arm - drifting with eyes closed for 10 sec 6a/b- Motor L/R leg - hold leg for 5 sec 7. Limb ataxia - touch nose and then your finger 8. Sensory loss 9. Best Language - aphagia 10. Dysarthria - slurred speech 11. Extinction & Inattention - formally neglect - recognition of own body
49
tPA for treatment of stroke
helps to treat an ischemic stroke. It breaks down the blood clot, restoring the flow of blood to the parts of the brain affected by the stroke. benefits outweigh the risks
50
Stroke: Diagnostics
CT w/ out contrast – assess for the presence of bleeding (hemorrhage bleeding) CT w/ contrast – rule out other lesions that mimic ischemia (obstructions) MRI – visualizes soft tissue and vascular structures (Useful in *diagnosing* a stroke in first 72 hours) MRA – more expensive, but useful for clot visualization (non-invasive) Carotid US – Non-invasive and is ordered to see if carotid endarterectomy is needed Transcranial Doppler (TCD) – Non-invasive monitoring of blood flow velocities in the major cerebral and carotid arteries to assess for stenosis Cerebral Angiography – defines the percentage of occlusion in patients with unusual presentation of symptoms, such as aneurysm, vasculitis, and high-grade stenosis TTE & TEE – echos completed in the thoracic and esophageal areas to determine where thrombi are coming from that could be causing a stroke ECG – assessing for atrial fibrillation Prothrombotic States – assessing for conditions associated with a high frequency of thrombosis
51
CT w/ out contrast
assess for the presence of bleeding (hemorrhage bleeding)
52
CT w/ contrast
CT w/ contrast – rule out other lesions that mimic ischemia (obstructions)
53
MRI
visualizes soft tissue and vascular structures (Useful in *diagnosing* a stroke in first 72 hours)
54
MRA
more expensive, but useful for clot visualization (non-invasive)
55
Carotid US
Non-invasive and is ordered to see if carotid endarterectomy is needed
56
Transcranial Doppler (TCD)
Non-invasive monitoring of blood flow velocities in the major cerebral and carotid arteries to assess for stenosis
57
Cerebral Angiography
defines the percentage of occlusion in patients with unusual presentation of symptoms, such as aneurysm, vasculitis, and high-grade stenosis
58
TTE & TEE
echos completed in the thoracic and esophageal areas to determine where thrombi are coming from that could be causing a stroke
59
ECG
rrassessing for atrial fibrillation Prothrombotic States – assessing for conditions associated with a high frequency of thrombosis
60
Stroke: Recovery
Acute Recovery Care -- BP in tight parameters, O2, Temp, CBG, frequent neuro assessment, DVT prophylaxis, cardiac monitor, swallow study Secondary Prevention -- High risk for another event -- Find source potential (e.g., cardiogenic) -- Anticoagulants -- Antiplatelets -- Statins
61
Stroke Rehab
Rehab facilities Begins at admission & is multidisciplinary Want history, behavioral characteristics, ADLs, & neuro scores to formulate a plan Goal: Return to baseline function Help to prevent- aspiration, incontinence, skin breakdown, falls, depression, family dynamic disruption
62
Stroke: Prevention
The usual…Eat right, exercise, stress less Primary prevention strategies - EDUCATE Prevent or treat hypertension, diabetes, dyslipidemia Stop smoking and decrease alcohol consumption Decrease weight, increase activity Adhere to prescribed medication regimen

Acute Care Exam 3 (4 decks)

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