Chapter 44 Problems of CNS: Brain

Question 1

Phases of Migraine with Aura (Classic): First/Prodromal Phase

Answer 1

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

Question 2

Phases of Migraine with Aura: Second Phase

Answer 2

headache is accompanied by nausea and vomiting

pain usually begins in the temple. it increases in intensity ad becomes throbbing within 1 hour

Question 3

Phases of Migraine with Aura: Third Phase

Answer 3

pain changes from throbbing to dull
headache, nausea, vomiting last 4-72hrs
(older pts may have migraine without aura aka visual migraine)

Question 4

Migraine without Aura (Common)

Answer 4

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

Question 5

Atypical Migraine

Answer 5

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

Question 6

Drugs for Migraine Headaches: Nonspecific Analgesic

Answer 6

acetaminophen
isometheptene
butalbital

Question 7

Drugs for Migraines: NSAIDS

Answer 7

ibuprofen

naproxen

Question 8

Drugs for Migraines: beta blockers

Answer 8

propranolol

timolol

Question 9

Drugs for Migraines: ergotamine preparations

Answer 9

ergotamine with caffeine (oral or suppository) Cafergot {Migergot})
ergotamine sublingual (SL) (Ergomar SL)
dihydroergotamine (DHE) nasal spray (migranal)

Question 10

Drugs for Migraines: Triptan Preparations

Answer 10

almotriptan (Axert)
Eletriptan (Relpax)
Rizatriptan (Maxalt)
Zolmitriptan (Zomig)
Sumatriptan (Imitrex)
Frovatriptan (Frova)

Question 11

Drugs for Migraines: Isometheptene Combination and Antiepileptic Drugs (AEDs)

Answer 11

Midrin

Divalproex (Depakote)
Topiramate (Topamax)

Question 12

Factors that may Trigger a Migraine Attack

Answer 12

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

Question 13

Herbs to Prevent Migraines

Answer 13

feverfew
bay
willow
ginger
red pepper
valerian
dong quai
ginkgo biloba
lavendar
lemon balm
peppermint
magnesium
purslane

Question 14

Seizures: Nursing Documentation and Observations (10)

Answer 14

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

Question 15

Common Bacteria that Meningitis

Answer 15

neisseria meningitidis
streptococcus pneumoniae
streptococci group A
staphylococcus aureus
escherichia coli
klebsiella
proteus pseudomonas
listeria monocytogenes
haemophilus influenzae (not as common bc immunization)

Question 16

Key Features of Meningitis

Answer 16

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)

Question 17

CSF differences in Bacterial and Viral Meningitis

Answer 17

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

Question 18

Care of pts with Meningitis

Answer 18

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

Question 19

Protecting from West Nile

Answer 19

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

Question 20

Stages of Parkinson’s (1-5)

Answer 20

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

Question 21

Parkinson’s: Posture

Answer 21

stooped posture
flexed trunk
finger abducted and flexed at the metacarpophalangeal joint
wrist slightly dorsiflexed

Question 22

Parkinson’s: Gait

Answer 22

slow and shuffling
short, hesitant steps
propulsive gait
difficulty stooping quickly

Question 23

Parkinson’s: Motor

Answer 23

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)

Question 24

Parkinson’s: Speech

Answer 24

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

Question 25

Parkinson’s: autonomic dysfunction

Answer 25

orthostatic hypotension
excessive perspiration
oily skin
seborrhea
flushing
changes in skin texture
blepharospasm (eyelid spasm)

Question 26

Parkinson’s: psychosocial assessment

Answer 26

emotionally labile
depressed
paranoid
easily upset
rapid mood swings
cognitive impairments (dementia)
delayed reaction time
sleep disturbances

Question 27

Care of Patient with Parkinson’s

Answer 27

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

Question 28

Causes of Cognitive Impairment in Older Adults: Neurologic Causes

Answer 28

vascular insufficiency
infections
trauma
tumors
normal pressure hydrocephalus

Question 29

Cognitive impairment in Older Adult: Cardiovascular Causes

Answer 29

myocardial infarction
dysrhythmias
heart failure
cardiogenic shock
endocarditis

Question 30

Cognitive Impairment in Older Adult: Pulmonary Causes

Answer 30

infection
pneumonia
hypoventilation

Question 31

Cognitive Impairment in Older Adult: Metabolic Causes

Answer 31

electrolyte imbalance
acidosis/alkalosis
hypoglycemia/hyperglycemia
acute renal failure and chronic kidney disease
fluid volume deficit and UTIs
hepatic failure

Question 32

Cognitive Impairment in Older Adult: Drug Intoxication

Answer 32

misuse of prescribed medications
side effects of medications
incorrect use of OTCs
ingestion of heavy metals

Question 33

Cognitive impairment in Older Adult: Nutritional/Environmental and Psych

Answer 33

B vitamins, vitamin C, hypoproteinemia
hypothermia/hyperthermia, unfamiliar environment, sensory deprivation/overload
depression, anxiety, pain, fatigue, grief, paranoia

Question 34

Key Features of Alzheimer’s Disease: Early Up to 4 years

Answer 34

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

Question 35

Key Features of Alzheimer’s Disease: Middle (Moderate) 2 to 3 years

Answer 35

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

Question 36

Key Features of Alzheimer’s Disease: Late (severe)

Answer 36

bedridden; completely incapacitated
totally dependent in ADLs
motor and verbal skills lost
general and focal neurologic deficits
agnosia (loss of facial recognition)

Question 37

Factors that can Worsen Alzheimer’s

Answer 37

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