Chapter 44 Problems of CNS: Brain Flashcards
Phases of Migraine with Aura (Classic): First/Prodromal Phase
aura develops over several minutes and lasts no longer than 1 hr
well defined transient focal neurologic dysfunction exists
pain may be preceded by: visual disturbances, flashing lights, lines or spots, shimmering or zigzag lights
pain may be preceded by a variety of neurologic changes: numbness, tingling lips or tongue, acute confusional state, aphasia, vertigo, unilateral weakness, drowsiness
Phases of Migraine with Aura: Second Phase
headache is accompanied by nausea and vomiting
pain usually begins in the temple. it increases in intensity ad becomes throbbing within 1 hour
Phases of Migraine with Aura: Third Phase
pain changes from throbbing to dull
headache, nausea, vomiting last 4-72hrs
(older pts may have migraine without aura aka visual migraine)
Migraine without Aura (Common)
migraine begins without an aura before onset of headache
pain is aggravated by performing routine physical activities
pain is unilateral and pulsating
one of these symptoms is present: nausea and/or vomiting
photophobia
phonophobia
headache lasts 4-72hrs
migraine often occurs in early morning, during periods of stress or in those with premenstrual tension or fluid retention
Atypical Migraine
status migrainous: headache lasts longer than 72 hours
migrainous infarction: neurologic symptoms are not completely reversible within 7 days. ischemic infarct is noted on neuroimaging
unclassified: headache does not fulfill all of the criteria to be classified a migraine
Drugs for Migraine Headaches: Nonspecific Analgesic
acetaminophen
isometheptene
butalbital
Drugs for Migraines: NSAIDS
ibuprofen
naproxen
Drugs for Migraines: beta blockers
propranolol
timolol
Drugs for Migraines: ergotamine preparations
ergotamine with caffeine (oral or suppository) Cafergot {Migergot})
ergotamine sublingual (SL) (Ergomar SL)
dihydroergotamine (DHE) nasal spray (migranal)Drugs for Migraines: Triptan Preparations
almotriptan (Axert) Eletriptan (Relpax) Rizatriptan (Maxalt) Zolmitriptan (Zomig) Sumatriptan (Imitrex) Frovatriptan (Frova)
Drugs for Migraines: Isometheptene Combination and Antiepileptic Drugs (AEDs)
Midrin
Divalproex (Depakote)
Topiramate (Topamax)
Factors that may Trigger a Migraine Attack
Teach pts to avoid the foods, meds and other factors that trigger
tyramine containing:
alcoholic drinks, aged cheese, caffeine in coffee, tea, cola, chocolate, foods with east like pastry and fresh breads, monosodium glutamate (MSG), nitrates (food preservative), pickled or fermented foods, nuts, artificial sweeteners, smoked fish
Drugs: dimetidine, estrogens, nitroglycerin, nifedipine (procardia, nifed)
other factors: anger, conflict, fatigue, hormonal fluctuations, menstruation, pregnancy, menopause, light glare, missed meals, psychological stress, sleep problems, smells like tobacco, travel to different altitudes
Herbs to Prevent Migraines
feverfew bay willow ginger red pepper valerian dong quai ginkgo biloba lavendar lemon balm peppermint magnesium purslane
Seizures: Nursing Documentation and Observations (10)
How often seizures occur: date, time, duration
Description of each seizure: tonic clonic, staring spells, blinking, automatism
whether more than one type of seizure occurs
sequence of seizure progression: where the seizure began, body part first involved
observations during the seizure: changes in pupil size and eye deviation, LOC, presence of apnea, cyanosis, salivation, incontinence of bowel or bladder during seizure, eye fluttering, movement and progression of motor activity, lip smacking or other automatism, tongue or lip biting
how long seizure lasts
when the seizure took place
whether seizures are preceded by an aura: dizziness, numbness, visual disturbances. gustatory or auditory disturbances
what the patient does after the seizure: feels drowsy or weak, may resume normal behavior, may be unaware that the seizure took place
how long it takes for patient to return to pre-seizure status
Common Bacteria that Meningitis
neisseria meningitidis streptococcus pneumoniae streptococci group A staphylococcus aureus escherichia coli klebsiella proteus pseudomonas listeria monocytogenes haemophilus influenzae (not as common bc immunization)
Key Features of Meningitis
Decreased LOC
Disoriented to person, place and year
Pupil reaction and eye movements: photophobia, nystagmus, abnormal eye movements
Motor Response: normal early in disease, hemiparesis, hemiplegia, and decreased muscle tone possible later, cranial nerve dysfunction especially CN III, IV, VI, VII, VIII
Memory Changes: attention span (usually short), personality and behavior changes, bewilderment
severe unrelenting headaches
generalized muscle aches and pain
nausea and vomiting
fever and chills
tachycardia
red macular rash (meningococcal meningitis)
CSF differences in Bacterial and Viral Meningitis
Bacterial: cloudy, turbid, increased WBC, increased protein, decreased glucose, elevated CSF pressure
Viral: clear, increased WBC, increased/slightly elevated protein, normal glucose but may be decreased, CSF pressure
Care of pts with Meningitis
ABCs
vital signs/neuro checks every 2-4 hours
craial nerve assessment esp. III, IV, VI, VII, VIII and monitor for changes
manage pain with drug and nondrug methods
give drugs and IV fluids and document response
perform vascular assessment and monitor for changes
record intake and output and prevent fluid overload
monitor body weight and identify fluid retention early
laboratory values, report abnormal
position carefully to prevent pressure ulcers
ROM q4hrs prn
decrease environmental stimuli: quiet environment, minimize exposure to bright lights, maintain bedrest with head of bed elevated 30 degrees
maintain transmission precautions
monitor for and prevent: increased ICP, vascular dysfunction, fluid and electrolyte imbalance, seizures, shock
Protecting from West Nile
limit time outside between dusk and dawn (mosquitos are out)
wear protective clothing including long sleeves and pants
use insect repellent containing DEET
remove areas of standing water from flower pots, trash cans and rain gutters
check window and door screens for holes
keep hot tubs and pools clean and properly chlorinated
Stages of Parkinson’s (1-5)
1 initial stage: unilateral limb involvement, minimal weakness, hand and arm trembling
2 mild stage: bilateral limb involvement, masklike facies, slow shuffling gait
3 moderate disease: postural instability, increased gait disturbance
4 severe disability: akinesia, rigidity
5: complete ADL dependence
Parkinson’s: Posture
stooped posture
flexed trunk
finger abducted and flexed at the metacarpophalangeal joint
wrist slightly dorsiflexed
Parkinson’s: Gait
slow and shuffling
short, hesitant steps
propulsive gait
difficulty stooping quickly
Parkinson’s: Motor
bradykinesia (slow movement) muscular rigidity akinesia tremors pill-rolling movement masklike facies difficulty chewing and swallowing uncontrolled drooling esp. at night fatigue difficulty getting into and out of bed reduced arm swinging on one side of the body when walking micrographia (change in handwriting or handwriting gets smaller)
Parkinson’s: Speech
soft low pitched voice
dysarthria (slurred speech)
echolalia (automatic repetition of what another person says), repetition of sentences
hypophonia (soft voice) change in voice volume or articulation
Parkinson’s: autonomic dysfunction
orthostatic hypotension excessive perspiration oily skin seborrhea flushing changes in skin texture blepharospasm (eyelid spasm)
Parkinson’s: psychosocial assessment
emotionally labile depressed paranoid easily upset rapid mood swings cognitive impairments (dementia) delayed reaction time sleep disturbances
Care of Patient with Parkinson’s
give time to respond to questions
administer meds on time
provide meds for pain, tingling limbs
monitor for SE (ortho hypo, hallucinations, and acute confusional state (delirium)
collaborate with PTOT to keep pt mobile
allow pt extra time to perform ADLs and mobility skills
interventions to prevent: constipation, pressure ulcers, and contractures
schedule appointments and activities late in morning to prevent rushing patient or schedule at optimum level of functioning
teach pt to speak slowly and clearly. use alternative communication methods such as communication board. refer to SLP
monitor ability to eat and swallow. monitor actual food and fluid intake. collaborate with nutritionist
provide high protein high calorie foods or supplements to maintain weight
assess for depression and anxiety
assess for insomnia or sleeplessness
Causes of Cognitive Impairment in Older Adults: Neurologic Causes
vascular insufficiency infections trauma tumors normal pressure hydrocephalus
Cognitive impairment in Older Adult: Cardiovascular Causes
myocardial infarction dysrhythmias heart failure cardiogenic shock endocarditis
Cognitive Impairment in Older Adult: Pulmonary Causes
infection
pneumonia
hypoventilation
Cognitive Impairment in Older Adult: Metabolic Causes
electrolyte imbalance acidosis/alkalosis hypoglycemia/hyperglycemia acute renal failure and chronic kidney disease fluid volume deficit and UTIs hepatic failure
Cognitive Impairment in Older Adult: Drug Intoxication
misuse of prescribed medications
side effects of medications
incorrect use of OTCs
ingestion of heavy metals
Cognitive impairment in Older Adult: Nutritional/Environmental and Psych
B vitamins, vitamin C, hypoproteinemia
hypothermia/hyperthermia, unfamiliar environment, sensory deprivation/overload
depression, anxiety, pain, fatigue, grief, paranoia
Key Features of Alzheimer’s Disease: Early Up to 4 years
independent ADLs
no social or employment problems initially
denies presence of symptoms
forgets names; misplaces household items
short term memory loss; difficulty recalling new information
subtle changes in personality and behavior
loss of initiative; less engaged in social relationships
mild cognitive impairment, problems with judgement
decreased performance, especially when stressed
unable to travel alone or to new destinations
decreased sense of smell
Key Features of Alzheimer’s Disease: Middle (Moderate) 2 to 3 years
impairment of all cognitive functions
problems with handling or unable to handle money and financies
disorientation to time. place and event
possible depression, agitated
increasingly dependent in ADLs
sicuospatial deficits; difficulty driving, gets lost
speeh and language deficits; less talkative, decrease in use of vocabulary, increasingly nonfluent and eventually aphasic
incontinent
wandering; trouble sleeping
Key Features of Alzheimer’s Disease: Late (severe)
bedridden; completely incapacitated totally dependent in ADLs motor and verbal skills lost general and focal neurologic deficits agnosia (loss of facial recognition)
Factors that can Worsen Alzheimer’s
stroke subdural hematoma space occupying lesion decrease in blood supply to brain myocardial infarction dysrhythmias hypoglycemia impaired renal function infection impaired vision and hearing sudden changes in surroundings pain and discomfort drugs physical or chemical restraint
