Chapter 44: Care Of Patients With Priblems Of The CNS: Brain Flashcards
Migraine headache
Typical migraine is described as unilateral, fronto-temporal, throbbing pain in the head that is often worse behind one eye or ear, often accompanied by a sensitive scalp, anorexia, photophobia (sensitivity to light and noise), and nausea with or without
A Migraine headache—chronic, episodic disorder with multiple subtypes
Classified as a long-duration headache because it usually lasts longer than 4 hours
Medication for migraines
Abortive therapy—alleviating pain during the early aura phase or soon after the headache has started:
ØDrug therapy to manage migraine HA’s
•Mild HA’s nonspecific analgesics Acetaminophen
•Mild HA’s nonsteroidal anti-inflammatory (NSAIDs) Ibuprofen or Naproxen, beta blockers Propranolol or Timolol
•Severe HA’s ergotamine preparations Cafergot, triptan preparataions Imitrex, isometheptene combinatiaon Midrin and antiepileptic drugs Epakote
•Triptan preparations such as Imitrex instruct patients to report chest pain or tightness immediately. They may also cause rebound HA
•Contraindicated in patients with actual or suspected ischemic heart disease, cerebrovascular ischemia, hypertension, peripheral vascular disease and those with Prinzmetal’s angina due to potential coronary vascular spasm
Preventive therapy: when migraine HA’s occur more than 2x/week, interfere with ADLs or not relieved with acute treatment
Interventions for migraine
The 3 R’s (National Headache Foundation):
ØRecognize migraine symptoms
ØRespond and see health care provider
ØRelieve pain and associated symptoms
The priority for care of the patient having migraines is pain management
Cluster headache
Cluster HA’s are manifested by brief intense unilateral pain that generally occurs in the spring and fall.
It is the most common chronic short-term HA with pain lasting less than 4 hours.
Men are affected 3-4 times more than women.
Histamine cephalalgia less common than migraines.
Cause unknown; attributed to vasoreactivity and oxyhemoglobin desaturation.
Unilateral, radiating to forehead, temple, or cheek, NONthrobbing
Ipsilateral tearing of the eye, rhinorrhea, ptosis, and miosis (pupil constriction)
They occur at the same time every day for about 4 to 12 weeks which is why they’re called cluster. You may have a period of remission for nine months afterwards.
Cluster headache treatment
Same types of drugs used for migraines
Patient to wear sunglasses and avoid sunlight
Oxygen via mask 7-10L for 15-30min
Avoidance of precipitating factors, such as anger, excitement
Surgical management if drug resistant
CAM for migraines
Yoga, meditation, massage, exercise, biofeedback, relaxation techniques
Acupuncture, use of herbs and nutritional therapies with approval
ØTriptan drugs should not be taken with selective serotonin reuptake inhibitor (SSRI) antidepressants or St. John’s wort, an herb used commonly for depression.
Avoidance of trigger events that may result in migraine episodes, such as tension and stress
Recommend at beginning of a migraine HA to reduce pain by lying down and darkening the room. Close or cover eyes and apply cool cloth to forehead.
If patient falls asleep, he/she should remain undisturbed until awakening.
Instruct patient to take preventive drugs regularly, avoid triggers and use complimentary alternative therapies to help them relax and avoid HA.
Emphasize a healthy lifestyle and avoid smoking, exercise regularly, eat a balanced diet, and get adequate rest and sleep.
Tension headache treatment
Tension HA’s are the most common type of chronic long-duration HA lasting more than 4 hours
Neck and shoulder muscle tenderness and bilateral pain at the base of the skull and in the forehead
Head pain without associated symptoms
Treatment—non-opioid analgesics, muscle relaxants, occasional opioids
Ibuprofen plus caffeine
Prophylactic treatment similar to that used in treating migraine headaches
Health teaching aides:
Lifestyle changes to include routine sleeping pattern, exercise, massage, yoga to reduce stress, and a healthy diet to include fruits and vegetables and to avoid fasting and triggers for headaches that include caffeine, smoking, pickled foods, and red wine.
Peppermint oil may halp
Seizure
Seizure—abnormal, sudden, excessive, uncontrolled electrical discharge of neurons within the brain; may result in alteration in consciousness, motor or sensory ability, and/or behavior
Secondary seizures—result from an underlying brain lesion, most commonly a tumor or trauma
Tension headaches
Tension HA’s are the most common type of chronic long-duration HA lasting more than 4 hours
Neck and shoulder muscle tenderness and bilateral pain at the base of the skull and in the forehead
Head pain without associated symptoms
Tonic-clonic seizure
Generalized seizures occur and involve both cerebral hemisipheres. There are 6 types and will discuss 2 types:
ØTonic-clonic last 2-5 minutes. Tonic phase is stiffening and rigidity of muscles and immediate loss of consciousness (LOC). Clonic is a rhythmic jerking of all extremities follows the tonic phase. May bite tongue, incontinent of urine or feces. Fatigue, confusion, and lethargy may last up to an hour after the seizure. Refer to Memory Notebook Vol. 2, 4th Ed, p. 130
Absence seizure
ØAbsence seizure common in children with LOC and blank staring may last for a few seconds with automatisms (involuntary behaviors) such as lip smacking and picking at clothes
Epilepsy
Epilepsy— defined by the National Institute of Neurological Disorders and Stroke as “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 (e.g., GABA)
Primary or idiopathic epilepsy is not associated with any identifiable brain lesion or other specific cause.
Seizure treatment with meds
Antiepileptic drugs (AEDs)
ØBe aware of drug-drug and drug-food interactions. Instruct patient to avoid drugs and foods that might interfere with the absorption or metabolism of the AED. For instance warfarin (Coumadin, Warfilone) should not be given with phenytoin (Dilantin)
Importance of compliance
ØTeach and emphasize patients to take their drugs on time and not to miss a dose to maintain therapeutic blood levels and maximum effectiveness
Health teaching
ØEmphasize that AEDs must not be stopped even if the seizures have stopped can lead to life threatening complication of status epilepticus
ØTeach importance of having serum drug levels monitored to ensure a therapeutic level, and assess for high levels that could indicate toxicity
Seizure precautions
Precautions are taken to prevent the patient from injury if a seizure occurs. Have to following:
Oxygen
Suction equipment
Airway
IV access, insert saline lock
Siderails up: Should be up and side rails are rarely the source of significant injury, follow hospital policy about use of side rails because now classified at a restraint
No tongue blades: padded tongue blades do not belong at the bedside and should NEVER be inserted into the patient’s mouth because the jaw may clench down as soon as the seizure begins. Forcing a tongue blade or airway into the mouth is more likely to chip the teeth and increase the risk of aspirating tooth fragments than prevent the patient from biting the tongue. Furthermore, improper placement of a padded tongue blade can obstruct the airway
Risk for seizure
Seizures may result from:
ØMetabolic disorders
ØAcute alcohol withdrawal
ØElectrolyte disturbances. Such as
hyperkalemia, water intoxication, and
hypoglycemia
ØHeart disease
ØHigh fever
ØStroke
ØSubstance abuse
These are not considered epilepsy. Increased physical activity, emotional stress, excessive fatigue, alcohol, caffeine, foods or chemical can trigger a seizure
Acute seizure management
Lorazepam (Ativan)
Diazepam (Valium)
Diastat (Diazepam rectal gel)
IV phenytoin (Dilantin) or fosphenytoin (Cerebrex) causes fewer cardiac problems than Dilantin and can be given in an IV dextrose solution
Status epilepticus
Medical emergency!
Prolonged seizures lasting more than 5 minutes or repeated seizures over the course of 30 minutes
It is a potential complication of all types of seizures!
Seizures lasting longer than 10 minutes can cause death!
Common causes: sudden withdrawal from AED’s, infections, acute alcohol or drug withdrawal, head trauma, cerebra edema, metabolic disturbances
Establish an airway is the top priority! Intubation by respiratory therapy (RT) or anesthesia may be necessary
ABGs
IV push drugs of choice lorazepam (Ativan), diazepam (Valium); rectal diazepam gel (Diastat)
Loading dose IV phenytoin to prevent additional tonic-clonic seizures or cardiac arrest
Seizure management
Precautions are taken to prevent the patient from injury if a seizure occurs. Have to following:
Oxygen
Suction equipment
Airway
IV access
Siderails up: Should be up and side rails are rarely the source of significant injury, follow hospital policy about use of side rails because now classified at a restraint
No tongue blades: padded tongue blades do not belong at the bedside and should NEVER be inserted into the patient’s mouth because the jaw may clench down as soon as the seizure begins. Forcing a tongue blade or airway into the mouth is more likely to chip the teeth and increase the risk of aspirating tooth fragments than prevent the patient from biting the tongue. Furthermore, improper placement of a padded tongue blade can obstruct the airway
Surgical management of seizures
Vagal nerve stimulation (VNS)
Conventional surgical procedures
Anterior temporal lobe resection
Partial corpus callosotomy
Care during a seizure
Protect from injury, do not put anything in mouth, turn to side, loosen restrictive clothing, maintain airway and suction, do not restrain, record the time seizure began and ended.
After take the patient’s vital signs, performed neurological checks, keep patient on side, allow patient to rest, document seizure
Meningitis
Meningitis—inflammation of the meninges that surround the brain and spinal cord
Viral meningitis—usually self-limiting and the patient has a complete recovery
Bacterial meningitis—potentially life-threatening
Regardless of the causative organism, symptoms are the same
The organisms responsible for meningitis enter the CNS via the bloodstream at the blood brain barrier (BBB). Direct routes of entry occur as a result of penetrating trauma, surgical procedures, or a ruptured cerebral abscess. Example, a basilar skull fracture can lead to meningitis as a result of the direct communication of CSF with the environment
Viral meningitis
Most common type
Results from a variety of viral illnesses including measles, mumps, herpes simplex and herpes zoster
No exudate and no organisms are obtained from the CSF.
Clinical manifestation of viral meningitis include fever, photophobia (light sensitivity), headache, myalgias (muscle aches), and nausea.
Bacterial meningitis
A medical emergency with a mortality rate of about 25%.
Occurs most often in the fall and winter when URIs commonly occur
Most frequent involved organism is Streptococcus pneumoniae (pneumococcal disease) and Nisseria meningitidis (meningococcal)
Meningococcal meningitis is the only type of bacterial meningitis that occurs in outbreaks. It is most likely to occur in areas of high population density, such as college dormitories, military barracks, and crowded living areas
The number of outbreaks on college campuses has been declining over the past few years because many states require students to be vaccinated against meningitis.
Teach people who live in highly populated areas the importance of getting the meningitis polysaccharide vaccine to prevent infection by certain groups of meningococcal bacteria.
Dilantin contraindication
Do not administer warfarin (Coumadin, Warfilone) with phenytoin (Dilantin) as this can interfere with the absorption or metabolism of antiepeliptic drugs (AEDs)
Document and report side and adverse effects and report to health care provider.
Meningitis labs
Cerebrospinal fluid analysis is the most significant laboratory test used to diagnose meningitis
CT or MRI scan to identify increased intracranial pressure, the presence of a brain abscess, or developing hydrocephalus
Blood cultures
Counterimmunoelectrophoresis to determine the presence of viruses or protozoa
Complete blood count (WBC is elevated)
Meningitis meds
Broad-spectrum antibiotics until results of culture and Gram stain are available. After available, the appropriate anti-infective drug to treat the specific type of meningitis is given. 2 weeks IV antibiotics is usually needed.
Hyperosmolar agents
Anticonvulsants
Steroids (controversial if they help)
Prophylaxis treatment for those who have been in close contact with the meningitis-infected patient
Bacterial meningitis CSF
ØAppearance cloudy, turbid ØWhite cells increased ØProtein increased ØGlucose decreased ØCSF pressure elevated
Viral meningitis CSF
ØAppearance clear ØWhite cells increased ØProtein increased slightly elevated ØGlucose most often normal may be decreased ØCSF pressure varies
Meningitis interventions
The most important nursing intervention for patients with meningitis is the accurate monitoring and recording of their neurologic status, vital signs, and vascular assessment.
Standard Precautions are appropriate for all patients with meningitis unless the patient has a bacterial type that is transmitted by droplets, such as Neisseria meningitides and Haemophilus influenzae. Patients with these infections should be placed on respiratory droplet precautions as well as Standard Precautions
See pic 44-8
Meningitis assessment
Perform a complete neurological and neurovascular assessment. Signs and symptoms of meningitis—headache, nausea, vomiting, and fever
Photophobia and indications of increased intracranial pressure
Nuchal rigidity (stiff neck) and positive Kernig’s (flexing the patient’s hip 90 degrees then extending the patient’s knee causes pain, and Brudzinski’s sign (flexing the patient’s neck causes flexion of the patient’s hips and knees)
Assess and monitor for early neurologic changes that may indicated increased intracranial pressure, such as a decrease in mental status or LOC. At risk for seizure, and hydrocephalus.
Excessive amounts of ADH are produced resulting in water retention
See picture 44-7
Encephalitis
Inflammation of the brain tissue and surrounding meninges; affects the cerebrum, the brain stem, and cerebellum
Caused by viral agents, bacteria, fungi, or parasites (malaria, West Nile virus mosquitoes; echovirus herpes virus, measles and mumps)
Degeneration of neurons of the cortex and demyelination of axons and destroys white matter and leads to hemorrhage, edema, necrosis, small lacunae develop in cerebral hemispheres
Viral encephalitis can be life-threatening and lead to learning disabilities, epilepsy, memory, or find motor deficits
Encephalitis interventions
Prompt recognition and treatment of signs of cerebral edema, hemorrhage, and necrosis of brain tissue
Establishment of patent airway to prevent development of atelectasis or pneumonia, which can lead to further brain hypoxia (lack of oxygen)
Assessment of vital signs
Continuous supportive care and assessment
Teach people who live in mosquito-infested areas to protect themselves and families from West Nile viral infections.
Treat with Acyclovir for herpes. None for other viruses.
Parkinson’s disease
Progressive neurodegenerative disease that is the third most common neurologic disorder of older adults
Tremor, rigidity, bradykinesia (slow movement), or akinesia (no movement). Cause unknown, may be due to environmental and genetic factors. Exposure to pesticides, herbicides, industrial chemicals or metals, drinking well water, over the age of 40 and reduced estrogen levels may contribute.
Neurotransmitters Dopamine (inhibit) and acetylcholine (ACh) checks and balances to excite muscles allowing voluntary control movement such a picking up a pencil and writing
A decrease in the amount of dopamine in the brain leads to a person’s ability to refine voluntary movement, and reduces the sympathetic nervous system influence to heart and blood vessels resulting in orthostatic hypotension
Assessment Parkinson’s disease
Fatigue, slight tremor, problems with manual dexterity
Rigidity is present early in the disease process
Changes in facial expression or a masklike facies with wide-open, fixed staring eyes are caused by rigidity of the facial muscles
Facial rigidity can cause uncontrolled drooling, difficulty in chewing and swallowing, and inadequate nutrition
Dementia as the disease progresses
Changes in voluntary movement, autonomic nervous system symptoms such as excessive perspiration, orthostatic hypotension
No specific diagnostic tests
Parkinson’s disease med therapy
Most important desired outcome is to improve mobility.
Dopamine agonists most effective the first 3-5 years of use. Fewer incidents of duskinesias (problem with movement) and “wearing off” phenomenon.
Catechol O-methyltransferases (COMTs) prolong the action of Levodopa.
Monoamine oxidase type B (MAO-B) inhibitors
Dopamine receptor antagonists for early and mild symptoms.
Neuro assessment meningitis
The priority for care is to monitor for early neurologic changes that my indicate increased ICP, such as decreased LOC.
The patient is also at risk for seizure activity
Assess cranial nerves III, IV, VI, VII, and VIII. A sixth cranial nerve defect (inability to move the eyes laterally) may indicate the development of hydrocephalus (excessive accumulation of CSF within the brain’s ventricles).
Other indicators of hydrocephalus include signs of increased ICP and urinary incontinence. Urinary incontinence results from decreasing LOC
Encephalitis assessment
Fever, nausea and vomiting, stiff neck, changes in mental status such as agitation, motor dysfunction such as dysphasia, focal neurological deficits, photophobia and phonophobia, fatigue, symptoms of increased pressure
Use the Glasgow coma scale to assess level of consciousness. Mental status changes are more extensive than with meningitis. The patient may have muscle tremors and jerks, increased deep tendon reflexes, seizures, vertigo,
Monitor for increased ICP such as a widened pulse pressure, bradycardia, irregular respirations, dilated pupils becoming less responsive,
Parkinson’s management
Exercise and ambulation to maintain strength, mobility and flexibility, and to prevent falls. Remind patient to avoid concentrating on his/her feet when walking to prevent falls
Self-management participate as much as possible
Injury prevention patient with PD tend to not sleep well at night due to drug therapy. Prone to injury and may fall asleep during the day. Avoid driving and operating machinery
Nutrition difficulty swallowing use small frequent meals or a commercial powder such as Thick-it, soft diet or thick, cold fluids, such as milk shakes are more easily tolerated
Communication speak slowly, pause, may need alternative methods such as voice synthesizer or personal digital assistant
Psychosocial support changes in gait and tremors incontrollable, assistance with movement, difficulty talking, drooling. Encourage to undertake activities large muscle activities
Surgical management Parkinson’s
ØStereotactic pallidotomy/thalamotomy
ØDeep brain stimulation
ØFetal tissue transplantation
Alzheimer’s
Chronic, progressive, degenerative disease that accounts for 60% of dementias occurring in people older than 65 years
Loss of memory, judgment, and visuospatial perception and change in personality
Increasing cognitive impairment, severe physical deterioration, death from complications of immobility
Age, gender (women more than men), and family history are important risk factors
Environmental agents, certain viruses such as herpes zoster and herpes simplex, and metals such as copper or zinc
Head injury or repeated head trauma (e.g., boxers)
Alzheimer’s changes in brain
Alzheimer’s disease creates changes that include:
ØNeurofibrillary tangles
ØNeuritic plaques
ØVascular degeneration
ØChanges in neurotransmitters
ØIncreased amounts of an abnormal protein, beta amyloid
Manifestations Alzheimer’s
Changes in cognition
ØOne of the first symptoms of AD is short-term memory
ØThere is increasing evidence that altered smell is associated with the development of AD
Alterations in communication and language abilities (inability to use objects correctly, inability to find words, and loss of sensory comprehension)
Changes in behavior, personality, and judgment (aggressiveness, especially verbal and physical abusive tendencies, rapid mood swings, and increased confusion)
Changes in self-care skills (decreased interest in personal appearance, loss of bowel and bladder control, decreased interest or ability to eat)
Psychosocial assessment, especially patient’s reaction to changes in routine
Alzheimer’s interventions
Answer patient’s questions truthfully.
Assess and treat other medical problems.
Provide cognitive stimulation and memory training.
ØIn later stages of AD, reality orientation does not work and often increases agitation. Use validation therapy that acknowledges the patient’s concerns and feelings. This does not argue with the patient and does not reinforce the patients wrong perception
Structure the environment to increase patient’s ability to function.
Prevent overstimulation and provide as much undisturbed sleep as possible
Orientation and validation therapy.
Promote self-management.
Promote bowel and bladder continence.
Assist with facial recognition.
Promote communication.
Parkinson’s disease drug toxicity
Long-term drug therapy regimens often cause delirium, cognitive impairment, decreased effectiveness of the drug (wearing off or loss of response to the drug), or hallucinations.
Reduce medication dose.
Change medications or frequency of administration.
Take “drug holiday,” especially in the use of levodopa therapy.
Monamine oxidase type B (MAO-B) inhibitors (MAOIs) are use in the early stage of Parkinson disease. Teach patients about the need to avoid foods, beverages, and drugs that contain tyramine, including aged, smoked, or cured foods and sausage. Avoid red wine and beer (not all alcohol) to prevent severe headache and life threatening hypertension. Continue these restrictions for 14 days after the drug is discontinued.
Parkinson’s disease nursing diagnoses
Impaired physical mobility, risk for falls, risk for self-care deficit, risk for impaired verbal communication, chronic confusion, risk for imbalance nutrition
Alzheimer’s rf injury
Interventions for the patient with Alzheimer’s disease include:
ØCoping with restlessness and wandering; ensuring patient wears identification bracelet; consider registering patient in Safe Return Program; may need to install alarms and deadbolts on outside doors, providing frequent walks and structured activities
ØEnsuring safety by removing all potentially dangerous objects, particularly in case seizures occur
ØMinimizing agitation by talking calmly and softly; displaying positive affect; making calm movements; offering diversion
Stages of Alzheimer’s
See 44-12
Family coping with Alzheimer’s
Interventions for the caregiver role:
ØEncourage family to seek legal counsel regarding patient’s competency, need to obtain guardianship, or durable medical power of attorney, when necessary.
ØMake caregivers and family aware of their own health and stress resulting from new responsibilities for care.
Disturbed sleep Alzheimer’s
Disturbed Sleep Pattern
Difficulty sleeping at night with frequent naps in the day
Interventions for establishing sleep pattern:
ØRe-establish the usual day-night pattern by providing activity and exercise during the day.
ØEstablish before-bedtime ritual.
ØAdjust treatment and medication schedule to provide for uninterrupted sleep.
ØGive mild antianxiety agent or hypnotic.
Alzheimer’s psychosocial assessment
Affects personality and behavioral changes. They often recognize it in the early stages and begin to grieve. Assess the patient’s reactions to changes which can be very traumatic. They may overreact to any change becoming excessively aggressive. They are often unaware of their behavior and the assessment shifts to the family. Assess the ability to cope with it.
Huntington disease
Hereditary disorder transmitted as an autosomal dominant gene (is from one parent in order for you to inherit the disease) trait at the time of conception
Movement disorder characterized by both neurologic and behavioral symptoms
Men and women affected equally and symptoms begin between 35 and 50 years of age.. Men often have more severe form.
Gradual clinical onset of progressive mental status changes, leading to dementia and choreiform jerky movements in the limbs, trunk, and facial muscles
Three stages, each lasting about 5 years over an average 15 years of the disease
People who inherit the mutation from fathers have an earlier onset and a shorter life expectancy
Management of huntingtons
No known cure or treatment
Genetic counseling (autosomal dominant)
Antipsychotic agents or monoamine-depleting agents used to manage movement abnormalities that are disabling or interfere with ADLs
Medications to treat depression, anxiety, and obsessive-compulsive behaviors
Imitrex/ sumatriptan
Triptan preparation
Contraindicated in patients with ischemic heart disease, cerebrovascular ischemia, hypertension, and peripheral
Take this medication as soon as migraine symptoms develop. Report chest pain or tightness to the doctor immediately. Use birth control while on this. Common side effects include flushing, tingling, and a hot sensation. These go away after you are used to the medicine. Do not take with an SSRI antidepressants or St. John’s wort.
Triggers for a headache
Caffeine, red wine, tyramine containing products such as pickled products, caffeine, beer, wine, preservatives, artificial sweeteners.
Aged cheese, chocolate, foods with yeast, monosodium glutamate, nitrates, nuts, smoked fish,
medications such as Tagamet, estrogens, nitroglycerin,
other factors such as anger, fatigue, menstruation, Light glare, missed meals, stress, sleep problems, smells, travel to different altitudes
Seizure nursing diagnosis
Risk for injury. Ineffective coping. Risk for ineffective breathing pattern. Potential for status epilepticus
Alzheimer’s health promotion
There are no ways to prevent Alzheimer’s. Eat a balanced diet, dark colored fruits and vegetables, use soy products, and get folate, vitamins B12, C, and E. They have been associated with a less risk of developing Alzheimer’s. Walking, swimming, exercising help decrease mental decline and dementia.
Dilantin phenytoin
Warfarin should never be given with Dilantin.
Always take the medication at the same time every day to maintain a therapeutic level.
Monitor for gastric distress, gingival hyperplasia, anemia, ataxia, and nystagmus. Check CBC and calcium levels. Monitor for therapeutic drug levels between 10 to 20 µg a toxic level is greater than 30. For IV Dilantin, flesh catheter with saline before and after.
Alzheimer’s med therapy
Donepezil, galantamine, rivastigmine Memantine Antidepressants Psychotropic drugs Drugs will not cure or improve AD but will help control emotional responses
Stages of a Migraine
ØProdrome: the patient has specific symptoms such as food cravings or mood changes
ØAura phase: (if present) involves visual changes, flashing lights, or diplobia (double vision)
ØHeadache phase: may last several hours to a few days
ØPostprodrome: patient is fatigued, irritable, and has muscle pain
