Exam III Flashcards
What are the conditions that can disrupt intracerebral perfusion?
- internal blockage of a vessel
- severe hypotension
- intracranial hemorrhage
- Loss of vessel integrity attributable to damage or excessive external pressure that exceeds perfusion pressure
This condition is the result of inadequate perfusion past a thrombus or embolus
Ischemic stroke
What are the most common inflammatory conditions of the brain?
- abscesses
- meningitis
- encephalitis
What population has a higher incidence of degenerative intracranial regulation problems?
The elderly
What population has a higher incidence of injury related intracranial regulation problems?
adolescent and young adult
Age, hypertension, diabetes, smoking, obesity, and cardiovascular disease are risk factors for _____?
Stroke
What are the three components of the skull?
- brain tissue (80%)
- blood (10%)
- cerebrospinal fluid (10%)
What is normal intracranial pressure?
Less than or equal to 15 mmHg
Intracranial pressure measuring greater than or equal to 20 mmHg is considered _____?
Intracranial hypertension
This is the capillary system of the brain consisting of a tight layer of endothelial cells located between the arterial and venous network?
Blood brain barrier
What is the function of the blood brain barrier?
It is a restrictive barrier that makes it difficult for neurotoxic substances to pass into the brain
What secondary condition compromises the blood brain barrier?
Decreased perfusion
The area of the brain between the arachnoid layer and the pia mater is referred to as the _____?
Subarachnoid space
The space contains cerebrospinal fluid
_____ is an inflammatory condition of the meninges
Meningitis
What are the three areas of the brain particularly sensitive to hypoglycemia?
- cerebral cortex
- hippocampus
- cerebellum
What are the detrimental effects of hyperglycemia with acute stroke?
- worsened ischemic damage
- increased infarction size
- increased blood brain permiability
Cerebral blood flow is normally maintained at a relatively constant rate by intrinsic cerebral mechanisms referred to as _____
Autoregulation
_____ adjusts cerebral blood flow in response to the brain’s metabolic demands by changing the diameter of cerebral blood vessels.
Autoregulation
The walls of these arteries are thinner because of a lack of smooth muscle and decreased thickness of the tunica media
cerebral
What are the three circumstances in which autoregulation becomes impaired?
- Mean arterial pressure <70mmHg or >170mmHg
- Intracranial Pressure >40 mmHg
- Localized or global cerebral injury
What is the rate of Cerebral Spinal Fluid production?
20 mL/hr
What are the six primary causes of cerebral edema?
- Mass lesions
- Head Injuries
- Brain Surgery
- Cerebral Infection
- Vascular Insult
- Toxic or Metabolic Encephalopathic conditions
What are the types of mass lesions that can cause cerebral edema?
- Brain abscess
- Brain Tumor (primary or metastatic)
- Hematoma (intracerebral, subdural, epidural)
- Hemorrhage (intracerebral, cerebellar, brainstem)
What are the complications that occur with head injuries and brain surgery that can cause cerebral edema?
- Contusion
- Hemorrhage
- Post traumatic brain swelling
What are the types of cerebral infections that can cause cerebral edema?
- Meningitis
- Encephalitis
What are the types of vascular insult that can cause cerebral edema?
- Anoxic and ischemic episodes
- Cerebral infarction (thrombotic or embolic)
- Venous sinus thrombosis
What are the toxic or metabolic encephalopathic conditions that can cause cerebral edema?
- Lead or arsenic intoxication
- Hepatic encephalopathy
- Uremia
____ is a compensatory mechanism that causes vasoconstriction, which reduces cerebral blood volume and ICP.
Hyperventilation
Carbon dioxide is a potent vasodilator
What is the intracranial pressure for Pathologic ICP?
Sustained pressure > or = to 20 mmHg
What conditions cause increased ICP?
- Traumatic brain injury (TBI
- Ruptured aneurysm
- CNS Infections
- Hydrocephalus
- Brain tumors
What are the symptoms of ICP?
- Headache
- Decreased LOC
- Vomiting
What are the signs of ICP?
- Cranial nerve VI palsies
- Papilledema
- Periorbital bruising
- Cushing’s triad
When doing a mental status exam what are the six categories to assess?
- general description
- emotional state
- experiences
- thinking
- sensorium
- cognition
What is the Glascow Coma Scale score for coma?
Adults < or = to 8
Children < or = to 5
Headache is an early sign of ICP for adults. What are the headache characteristics associated with increased ICP?
- Nocturnal awakening
- Pain worsened by cough/defication
- Progressive increase of frequency or severity
- Vomiting (not proceeded by nausea)
What are the symptoms of increased ICP for infants?
- Irritability
- Bulging fontanel
- Lethargy
- Flat affect
- Poor feeding
Retinal hemorrhage with increased ICP should raise suspicion of nonaccidental head trauma
At what level of Cerebral Perfusion Pressure is cerebral blood flow compromised and autoregulation impaired?
< 60 mmHg
What is the normal rate for cerebral perfusion pressure?
between 60 and 70 mmHg
Risk for adult respiratory distress syndrome occurs when CPP level are ______?
> 70 mmHg
What is the appropriate CPP level for children?
50 to 60 mmHg
Not well established
What are the different pharmacotherapies for intracranial regulation?
- Osmotic diuretics
- Sedatives
- Analgesics
- Antiepileptics
- Glucocorticoids
- Antipyretics
- Anti-hypertensives
- Anti-Parkinsonians
- Cholinesterase inhibitors
Which osmotic diuretics are commonly used for intracranial regulation?
Mannitol
Which sedatives are commonly used to decrease ICP by reducing metabolic demand?
- Propofol (Diprivan)
- Lorazepam (Ativan)
Which analgesics are used for intracranial regulation?
- Fentanyl (less effects on BP)
- Morphine
Which antiepilectics are used for intracranial regulation?
- Phenytoin (Dilantin)
- Valproic acid (Depakote)
Which glucocorticoids are indicated for cerebra edema related to tumors, abscesses, and CNS infections?
Dexamethasone (Decadron)
Which anti-hypertensives are used for intracranial regulation?
- Labetalol (Trandate): 1st choice
- Transdermal nitroglycerin paste
- Intravenous Nicardipine (Cardene)
Which Anti-Parkinsonian dopaminergic drugs are used for intracranial regulation?
- Levadopa (Sinemet): most common
Replaces dopamine, increasing the level in the brain. Given with carbidopa which prevents the conversion to dopamine until Levadopa reaches the brain.
Which Anti-Parkinsonian dopamine agonist drugs are used for intracranial regulation?
- Pramipexole (Mirapex)
- Ropinirole (Requip)
- Bromocriptine (Cycloset)
These mimic the effect of dopamine by stimulating the same cells as dopamine
Which cholinesterase inhibitors are used for mild to moderate dementia/intracranial regulation?
- Donepezil (Aricept)
- Rivastigmine (Exelon)
- Galantamine (Reminyl)
Which cholinesterase inhibitors are used for moderate to severe dementia/intracranial regulation?
- Memantine (Namenda)
What is the purpose of a decompressive craniotomy?
It removes rigid confines of the skull, allowing for expansion or cranial contents and lowers ICP
Complications include herniation, spinal fluid leak, infection, and hematoma (epidural and subdural)
What is the purpose of a craniotomy?
- remove lesions or tumors
- repair damages area
- relieve pressure
- drain blood from hematoma
What is the purpose of Stereotactic procedures?
- dissection
- biopsy
What is the purpose of Shunt procedures?
creates an artificial pathway for excessive CSF to drain from the brain
What is the proper positioning of the head for a patient with ICP?
- HOB 30 degrees
- Head midline
True/False
Patients with ICP should have all nursing care and tasks clustered at once.
False
This will increase oxygen demand and may compromise cerebral perfusion. Care and tasks should be distributed over a longer period of time.
True/False
Suctioning of patients with ICP causes no harm and should be performed as needed.
False
Suctioning stimulates coughing which increases ICP. If suctioning is absolutely necessary patient may need to be sedated.
True/False
Prophylactic hyperventilation in TBI is not recommended because it increases perfusion.
True
This negatively impacts oxygen delivery. This should only be done temporarily to reduce elevated ICP
This is caused by an interruption of perfusion to any part of the brain
Stroke
What are the two things the brain cannot store?
- Oxygen
- Glucose
Cerebral tissue death is called an ____
infarction
What are the two classifications of stroke?
- Ischemic (occlusive)
- Hemorrhagic
What are the two types of ischemic strokes?
- Thrombotic
- Embolic
This type of stroke is sudden but can be gradual if caused by HTN?
Hemorrhagic
With this type of stroke the patient is typically awake?
Ischemic
With this type of stroke the patient is typically in a deepened stupor or comatose?
Hemorrhagic
What are the two contributing factors for thrombotic stroke?
- HTN
- Atherosclerosis
What is the contributing factor for embolic stroke?
Cardiac Disease
What are the two contributing factors for hemorrhagic stroke?
- HTN
- Vessel disorders
This type of stroke usually presents with seizures?
Hemorrhagic
In this type of stroke the CSF presents bloody?
Hemorrhagic
In this type of stroke the CSF presents normal?
Ischemic
Protein may be present with thrombotic stroke
What are the neurologic deficits with thrombotic stroke and when do they present?
Deficits during the first few weeks
- slight headache
- speech deficits
- visual problems
- confusion
What are the neurologic deficits with embolic stroke and when do they present?
Maximum deficit at onset
- paralysis
- expressive aphasia
What are the neurologic deficits with hemorrhagic stroke?
Severe, frequent focal deficits
What is the duration of effects from a thrombotic stroke?
Improvements over weeks to months with permanent deficits possible
What is the duration of effects from a embolic stroke?
Rapid improvements
What is the duration of effects from a hemorrhagic stroke?
Variable recovery with permanent neurologic deficits possible
This type of stroke most often occurs in patients with A-fib, heart valve disease, prosthetic heart valves, or with mural thrombi after an MI
embolic stroke
Which type of hemorrhage is caused by sustained HTN ?
Intracerebral hemorrhage
Which type of hemorrhage is caused by a ruptured aneurysm, arteriovenous malformation, or trauma?
Subarachnoid hemorrhage
This condition occurs during embryonic development and is a tangled collection of malformed, thin walled, dilated vessels without a capillary network?
Arteriovenous malformation (AVM)
This is a sudden and periodic constriction of a cerebral artery that often follows a subarachnoid hemorrhage or bleeding from an aneurysm or AVM rupture?
Vasospasm
results in reduced perfusion and contributes to secondary cerebral ischemia and infarction
What type of diet is recommended for stroke prevention?
- High fruits/vegetables
- Low saturated fats
- Light to moderate alcohol consumption
Which ethnic group has the highest prevalence of stroke?
- American Indian
- Alaskan Native
Black men/women have higher instance of stroke thn white
What are the modifiable risk factors for stroke?
- Smoking
- Substance use (particularly cocaine)
- Obesity
- Sedentary lifestyle
- Oral contraceptive use
- Heavy alcohol use
- Use of phenylpropanolamine (PPA), found in antihistamine drugs
This type of stroke tends to occur during activity?
hemorrhagic stroke
What questions are necessary when a stroke is suspected?
- activity when stroke began
- how did symptoms progress
- time symptoms began
- severity of symptoms (getting better or worse)
- visual problems
- gait problems
- changes with reading/writing
What assessments should be done when a stroke is suspected?
- LOC
- cognitive/memory impairment
- difficulties with speech/hearing
- check for hypoglycemia (w/decreased LOC)
- o2 saturation
What medical history is important to collect with suspected stroke?
History of:
- HTN
- Diabetes
- Heart disease
- head trauma
- anemia
- obesity
- personal habits (smoking, drug use)
What are symptoms of subarachnoid hemorrhage?
- headache (worst ever)
- nausea/vomiting
- photophobia
- cranial neuropathy
- stiff neck
- change in mental status
What are the five most common symptoms of stroke?
- Sudden confusion or trouble speaking or understanding others
- Sudden numbness or weakness of the face, arm or leg
- Sudden trouble seeing in one or both eyes
- Sudden dizziness, trouble walking, or loss of balance/coordination
- Sudden severe headache with no known cause
To assess cognition changes check for which four signs?
- Denial of illness
- Spatial and proprioceptive dysfunction
- Impairment of memory, judgement, or problem solving and decision making abilities
- Decreased ability to concentrate and attend to tasks
What are the signs of right cerebral hemorrhage?
- Spatial and proprioceptive dysfunction
- Disoriented to time, place, and person
- Inability to recognize faces
- Personality changes such as poor impulse control and poor judgement
- Impaired sense of humor
- Loss of depth perception
- Visual special deficits
- Neglect of left visual field
- Impulsiveness
- Lack of awareness of neurologic deficits
- Confabulation
- Euphoria
- Constant smiling
- Denial of illness
- Poor judgement
- Overestimation of abilities
- Loss of ability to hear tonal variations
What are the signs of left cerebral hemorrhage?
- Aphasia (inability to use or understand language)
- Alexia/Dyslexia (reading problems)
- Agraphia (difficulty with writing)
- Acalculia (difficulty with math calculations)
- Possible memory deficits
- Deficits in right visual field
- Slowness
- Cautiousness
- Anxiety when attempting a new task
- Depression r/t illness
- Sense of guilt
- Feelings of worthlessness
- Worries over future
- Quick to anger and feelings of frustration
- No hearing changes
What are the motor changes that take place with stroke?
- Hemiplegia/Hemiparesis
- Hemiparesis/Quadriparesis (w/brainstem or cerebellum damage)
- Hypotonia/Flaccid Paralysis (reduced muscle strength)
- Hypertonia/Spastic paralysis (contractures)
What are the sensory changes that take place with stroke?
- decreased sensation on affected side
- Unilateral body neglect (primarily w/right cerebral hemisphere stroke)
- pupil constriction/dilation
- ptosis
- visual field deficits
- pallor and petechiae of the conjunctiva
- amaurosis fugax (brief episode of blindness in one eye)
- hemianopsia (blindness in half of the visual field)
- nystagmus
What is the name for a brief episode of blindness in one eye?
Amaurosis fugax
What is the name for blindness in half of the visual field?
Hemianopia
What is the name for blindness in half of the visual field of both eyes (same side)?
Homonymous Hemianopia
What is the name for blindness in half of the visual field of both eyes (opposite sides)?
Bi-temporal Hemianopia
Patients with this type of stroke may have a heart murmur, dysrhythmias (a-fib), or hypertension
Embolic stroke
What is the blood pressure necessary to maintain cerebral perfusion after an acute ischemic stroke?
150/100 mmHg
higher pressure may lead to another stroke
A patient who laughs and then cries unexpectedly for no apparent reason suffers from what condition?
Emotional lability
Which labs are drawn and what potential lab results are associated with stroke?
- increased H&H (compensation for lack of oxygen)
- increased WBCs (infection/inflammation)
- increased cardiac enzymes (if cardiac causes of stoke)
PT/INR and PTT are requested to establish baseline in the event anticoagulant therapy is needed
What is the purpose of performing a CT without contrast for the possible stroke patient?
- Ischemic or occlusive stroke initially negative, indicating thrombotic or embolic stroke rather than intracerebral hemorrhage
- Establishes baseline for future CTs
What is the purpose of performing an MRI for a possible stroke patient?
- Ischemic brain injury detected earlier than with CT
Which EKG findings are typical with stroke patients (and other cardiac diseases)?
- Inverted T-wave
- ST depression
- prolonged QT interval
What are the priority interventions for a patient experiencing an ischemic stroke?
- Continually assess for ICP
- Start 2 IV lines
- Place patient in supine position w/low HOB elevation (25 degrees or less for maximum perfusion/30 degress or more can improve oxygenation and reduce aspiration)
What is the drug used to treat acute ischemic stroke?
Alteplase (Activase)
What is the mechanism of action of Alteplase (Activase)?
It is a fibrinolytic that activates plasminogen to degrade the thrombus
What is the recommended time interval for administration of Alteplase (Activase)?
3 to 4.5 hours
What is the administration dosage and administration protocol for Alteplase (Activase)?
- Dosage based on weight
- 10% of dose given as bolus over 1 minute
- remainder of dose given over 1 hour
What is the recommended endovascular intervention for patients with occlusion of the middle cerebral artery or those past the rtPA window?
Intra-arterial thrombolysis
may be given up to 6 hours after onset of stroke
What is the recommended treatment for patients who arrive less than 8 hours after stroke?
Mechanical embolectomy (manual removal of blood clot)
When discharging a patient after carotid stent placement, what is the patient education that must be provided with regard to when to call the doctor?
- Severe headache
- Change in level of consciousness or cognition
- Muscle weakness or motor dysfunction
- Severe neck pain
- Neck swelling
- Hoarseness or difficulty swallowing
This post endovascular procedure complication has a high mortality and morbidity rate?
Hyperperfusion syndrome (May be associated with intracranial hemorrhage and may occur within 24 hours to 1 week after procedure)
What are the signs and symptoms of hyperperfussion?
- severe temporal headache
- hypertension
- seizures
- focal neurologic deficits
When is a stroke patient most at risk for increased ICP resulting from edema?
during the first 72 hours after onset of stroke
How often should patients be assessed after endovascular treatment and stroke?
every 1 to 4 hours (depending on condition)
What is the first sign of increased ICP?
declining LOC
True/False
Care of stroke patients should be clustered
False
too much activity at one time can cause a dramatic increase in ICP
True/False
Stroke patients should be hyperoxygenated before suctioning
True
This can avoid transient hypoxemia and result in elevated ICP from dilation of cerebral arteries.
True/False
Coughing and suctioning increase ICP
True
What assessments are important after stroke?
- BP
- Heart rhythm
- O2
- glucose
- temperature
Keeping these things in line may prevent secondary brain injury after stroke
What are the signs/symptoms of ICP?
- Decreased LOC
- Behavioral changes (restless, confused, irritable)
- Headache
- Nausea/Vomiting
- Change in speech pattern
- Pupillary changes
- Seizures
- Cushing’s Triad
- Abnormal posturing
These two conditions may present in patients with aneurysm or arteriovenous malformation (AVM)?
- Hydrocephalus (can occur when there is blood in the CSF as this prevents CSF from being reabsorbed)
- Vasospasm (can result in permanent irreversible neurologic impairment)
An initial dose of this medication is recommended within 24 to 48 hours after stroke onset?
Aspirin - 325mg
DO NOT give aspirin within 24 hours of rtPA administration
This medication crosses the blood brain barrier and treats/prevents cerebral vasospasm after subarachnoid hemorrhage.
Nimodipine (Nimotop)
What is the mechanism of action for Nimodipine (Nimotop)
Relaxes the smooth muscles of vessel walls and reduces incidence and severity of spasms
What are the 8 core measures for ischemic stroke care?
- Venous thromboembolism (VTE) prophylaxis
- Discharge with antithrombotic therapy
- Anticoagulation therapy for A-fib/flutter
- Thrombolytic therapy (for thrombotic stroke of <4 hours from symptom onset)
- Antithrombolytic therapy
- Discharged on statin therapy
- Stroke education
- Assessed for rehabilitation
This condition is an inflammation of the meninges, specifically the pia mater and arachnoid?
Meningitis
What are the types of meningitis?
- Viral
- Bacterial
- Fungal
- Protozoal
What is the most common type of meningitis?
Viral (aseptic)
How do the organisms that cause meningitis enter the bloodstream?
- Surgical procedures
- Penetrating trauma
- Ruptured abscess
- Basilar skull fracture (causing CSF leak to drain through nose and ears)
- Infections (eye, ears, nose, mouth)
What are the common viral organisms that cause meningitis?
- enterovirus
- herpes simplex virus 2
- varicella zoster virus
- mumps virus
- HIV
Which type of meningitis typically results in full recovery?
Viral meningitis
What are the findings in CSF from a lumbar puncture with viral meningitis?
- Clear CSF
- Normal/Slightly elevated glucose
Which type of meningitis is a medical emergency and has a high mortality rate?
Meningococcal meningitis
death often occurs within 24 hours
What are the common bacterial organisms that cause meningitis?
- Streptococcus pneumoniae
- Neisseria meningitides
This type of meningitis often occurs in areas with high population density such as dormitories, military barracks, and crowded living areas
Meningococcal meningitis
What are the findings in CSF from a lumbar puncture with bacterial meningitis?
- Cloudy CSF
- Decreased glucose
What is the CDC recommendation for meningococcal vaccination?
- initial dose: ages 11-12
- booster: age 16
- Adults should have initial or booster if living a shared residence such as dorms, barracks, group home; traveling to areas where disease is prominent; are immunocompromised
- safe to receive booster 8 weeks after initial dose
What are the clinical manifestations of meningitis?
- Decreased/changed LOC
- Nuchal regidity
- Disoriented to person, place, time
- Photophobia/Phonophobia (light/sound)
- Nystagmus
- Short attention span
- Personality/Behavior changes
- Hemiparesis/palegia, decreased muscle tone (later)
- Severe headache
- Generalized muscle aches and pains
- Nausea/Vomiting
- Fever/Chills
- Tachycardia
- Maculopapular rash (w/viral meningitis from enterovirus)
- Petechial rash (w/bacterial from Neisseria meningitis)
- Seizures (may occur)
- Bulging fontanel (babies)
What type of meningitis causes petechial rash?
Bacterial - caused by Neisseria meningitis
What type of meningitis causes Maculopapular rash?
Viral - caused by enterovirus
What is a positive Kernig’s sign?
Patient lays supine, when flexing the patient’s hip 90 degrees then extending the patient’s flexed knee, pain is caused
What is a positive Brudzinski’s sign?
Patient lays supine, flexing of the patient’s neck causes flexion of the patient’s hips and knees
What are the complications of meningitis?
- Increased ICP: can lead to herniation of brain and death
- Seizures: caused when inflammation spreads to cerebral cortex
- Systemic Inflammatory Response Syndrome (SIRS): reaction to endotoxin produced by infecting bacteria of activation of immune cells… caused rapid decrease in BP, tachycardia, coagulation issues
What vascular status assessments should be done by the nurse?
- Color/Temp of extremities
- Presence of peripheral pulses
- indicators of abnormal bleeding
- Capillary refill
What tests are done to determine meningitis?
- CT/MRI to determine presence of abscess, hydrocephalus, increased ICP
- Lumbar puncture for CSF collection
- Culture/Sensitivity
- Counterimmunoelectrophoresis (CIE) to determine presence of virus or protozoa (always performed if antibiotic given prior to LP to collect CSF)
- Urine, throat and nose cultures are collected to perform gram stains to determine bacterial source
- Xrays of chest, sinuses to determine presence of infection
What is the protocol for patient positioning after lumbar puncture?
Patient should lie supine and flat for 4 hours post procedure to prevent CSF leak and spinal headache
What patient education should be provided to avoid meningitis?
- Vaccinations: MMR, Hib, pneumococcal, varicella
- Thorough hand washing
What is the priority intervention for patients with meningitis?
- Accurately monitoring/documenting neuro status (every 4 hours or less if clinically indicated)
What are the nursing interventions for a patient with meningitis?
- ABCs
- Vitals
- Neuro checks every 2-4 hours
- Cranial nerve assessment
- Pain management
- Vascular assessment
- Medication/Fluid administration as prescribed
- Monitor I/Os, manage fluid/electrolyte balance
- Decrease environmental stimuli
- HOB elevation at 30 degrees
What type of fluids are given for patients with increased ICP?
Hypertonic - fluid needs to be removed from cells
What is the prophylaxis treatment for those exposed to N. Menigitidis?
- Rifampin (Rifadin, Rofact)
- Ciprofloxacin (Cipro)
- Ceftriaxone (Rocephine)
Rifampin may also be used for prophylaxis fo those exposed to H. influeszae meningitis
What type of precautions are used for a patient with bacterial meningitis?
Droplet precautions
This condition is an inflammation of the brain tissue and often the surrounding meninges. It effects the cerebrum, brainstem, and cerebellum?
Encephalitis
This type of virus is caused by a bite from a tick or mosquito?
Arbovirus
What is the common cause of encephalitis?
Virus
Also caused by bacteria, fungi or parasites
True/False
Viral encephalitis can be life threatening and lead to persistent neurological problems such as learning disabilities, epilepsy, memory deficits or fine motor deficits?
True
Quick response to signs and symptoms minimizes the effects of the disease
How do meningitis and encephalitis differ?
- Meningitis causes pus formation (exudate)
- Encephalitis inflammation extends over the cerebral cortex, white matter and meninges, causing degeneration of the neurons of the cortex.
- Meningitis inflammation extends to the pia mater and arachnoid
- Most cases of meningitis are recoverable
- Encephalitis is more life threatening and dangerous
- Mental status changes are more extensive with encephalitis
True/False
Meningitis causes demyelination of axons due to white matter destruction which leads to hemorrhage, edema, necrosis, and development of lacunae
False
These are all effects of encephalitis
What results in widespread edema with encephalitis?
- Compression of blood vessels
- Increased ICP
- Death from herniation and increased ICP
What is the incubation period for West Nile Virus?
2 to 15 days after being bitten by infected mosquito
How is encephalitis transmitted?
- Blood products
- Breast milk
- Organ transplant
- Mosquitos/Ticks
What are the diagnostic tests to determine the presence of West Nile Virus?
- Enzyme-linked immunosorbent assay
- West Nile virus-specific immunoglobulin M (IgM) antibody in blood or CFS
What are the symptoms of a mild case of West Nile virus?
- fever
- body aches
- nausea
- vomiting
What are the symptoms of a moderate/severe case of West Nile virus?
- high fever
- severe headache
- decreased LOC
- tremors
- vision loss
- seizures
- muscle weakness/paralysis
How long do the manifestations of West Nile virus persist?
Several weeks
Neurological deficits may be permanent
What is the most common non-epidemic type of encephalitis?
Herpes simplex virus I (HVS1)
Mortality rate for this type are high in comparison to other types of encephalitis
What are the common enteroviruses associated with encephalitis?
- Echovirus
- Coxsackievirus
- Poliovirus
- Herpes zoster
- Viruses that cause mumps and chickenpox
Amebic meningoencephalitis is caused by the amebae Naegleria and Acanthamoeba, where are these amoeba found?
- Soil and decaying vegetation
- Ponds and lakes
They enter via the nasal mucosa
What are the signs and symptoms of encephalitis?
- changes in metal status (agitation)
- motor dysfunction (dysphasia)
- Focal neurologic deficits
- Photophobia/Phonophobia (light/sound)
- Fatigue
- Symptoms of increased ICP (decreased ICP)
- Joint pain
- Headache
- Vertigo
What are the mental status changes that can take place with encephalitis?
- confusion
- irritability
- personality/behavior changes (especially w/herpes simplex)
The herpes zoster lesion affects cranial and spinal nerve root ganglia. What are the manifestations?
- Rash
- Severe pain
- Itching/Burning/Tingling near innervation of nerves
What are the diagnostic tests for encephalitis?
- LP to evaluate CSF
- Polymerase chain reaction (PCR) test to detect viral DNA or riboneucleic acid (RNA) in CSF
- electroencephalogram to evaluate brain wave activity and detect seizures
- CT to determine presence of ICP or obstructive hydrocephalus
What is the treatment for encephalitis?
Acyclovir (Zovirax) is the antiviral drug used for herpes encephalitis and is most effective when used early in onset
When does neurologic decline occur with encephalitis?
within 4 to 6 days after initial neurologic symptoms
What is the drug therapy for arboviruses and enteroviruses?
NONE
This is a chronic disorder in which repeated unprovoked seizure activity occurs
Epilepsy
What is the cause of epilepsy?
- abnormality in electrical neuronal activity
- imbalance of neurotransmitters (especially GABA)
- combination of both the above
What are the three types of seizures?
- generalized seizures
- partial seizures
- unclassified seizures
What are the five types of generalized seizures that may occur in adults and involve both cerebral hemispheres?
- Tonic-clonic
- Tonic
- Clonic
- Myoclonic
- Atonic
This type of generalized seizure is an abrupt increase in muscle tone, loss of consciousness, and autonomic changes that last from 30 seconds to several minutes?
Tonic seizure
This type of generalized seizure causes a sudden loss of muscle tone that lasts for seconds and is followed by a period of confusion. Patients with these seizures often fall causing injury. This type of seizure is resistant to drug therapy.
Atonic seizure
This type of generalized seizure stiffening or rigidity of the muscles, particularly of the arms and legs, and immediate loss of consciousness. Rhythmic jerking of all extremities follows. Patient may bite their tongue and become incontinent of urine or feces. Seizures last from 2 to 5 minutes. Fatigue, acute confusion, and lethargy may last up to an hour after this type of seizure.
Tonic-Clonic seizure
This type of seizure causes brief jerking or stiffening of the extremities that may occur singly or in groups. The last for a few seconds and contractions may be symmetrical or asymmetrical.
Myoclonic Seizure
This type of seizure causes muscle contraction and relaxation and lasts several minutes.
Clonic Seizures
This type of seizure begins in part of one cerebral hemisphere and are most often seen in adults and are generally less responsive to medical treatment.
Partial Seizures
This type of seizure may cause loss of consciousness for 1 to 3 minutes. The patient may wander unaware of the environment at the start of the seizure. There is often a period of amnesia after the seizure.
Complex Partial Seizures
Occurs in the temporal lobe and is also called psychomotor or temporal lobe seizures
Which type of seizure has symptoms that appear similar to dementia, psychosis, or other neurobehavioral disorders and is therefore difficult to diagnose, especially in the postictal stage (after seizure)
Complex partial seizures
Which type of seizure often comes with an aura prior to onset?
Simple Partial Seizures
This type of seizure accounts for half of all seizures and occurs for no known reason
Unclassified/Idiopathic Seizures
Which drugs should not be given with the antiepileptic drug Phenytoin (Dilantin)?
Warfarin (Coumadin)
Grapefruit interferes with metabolism of the drug and can raise the blood level of the drug
This condition is a medical emergency and is a prolonged seizure lasting longer than 5 minutes or repeated seizures over the course of 30 minutes.
Status Epilepticus
What are the common causes of status epilepticus?
- Sudden withdrawal of antiepileptic drugs
- Infection
- Acute alcohol/drug withdrawal
- Head trauma
- Cerebral edema
- Metabolic disturbances
What are the drugs of choice to treat status epilepticus?
- Lorazepam (Ativan)
- Diazepam (Valium)
- Phenytoin (Dilantin
What are the surgical interventions for epilepsy?
- Vagal nerve stimulation
- Partial Corpus Callosotomy
- Partial craniotomy
What are the complication of Vagal Nerve Stimulation?
- Hoarseness (common)
- Cough
- Dyspnea
- Neck pain
- Dysphasia
What is the patient teaching after Vagal Nerve Stimulation?
- Avoid MRI
- Avoid micowaves
- Avoid shortwave radios
- Avoid ultrasound diathermy
- Use magnet when aura presents to avoid seizure
Which patients are candidates for conventional surgical procedures for control of seizures?
- Those whose epilepsy/seizures cannot be controlled with medication
- Those with complex partial seizures in the frontal or temporal lobe
This disease is described as a change in the brain that disrupts a person’s interpretation and/or experience of the world secondary to complex neurological changes; hallucinations, delusions and/or disorganized thinking are hallmark characteristics.
Psychosis
This is a false distortion in perception and can be visual, auditory, gustatory, olfactory, or tactile?
Hallucincation
i.e. seeing/hearing things
This is a false fixed belief
Delusion
i.e. “they’re out to get me”
This type of psychosis is reversible and may last from weeks to months
Acute psychosis
This type of psychosis occurs when symptoms are primarily irreversible
Chronic psychosis
These two cognitive impairments have rapid onset
- Delirium
- Psychosis
This cognitive impairment has slow onset
Dementia
This cognitive impairment has impaired orientation
Dementia - often presents with confusion
This cognitive impairment presents with delusions
Psychosis
With this cognitive impairment speech is incoherent
Delirium
With this cognitive impairment speech is rapid and pressured
Psychosis
What are the medical conditions associated with psychosis?
- Brain injury
- Neurologic disease
- Hepatic disease
- Renal disease
- Autoimmune disease
- Fluid/Electrolyte imbalance
- Huntington’s chorea
- Epilepsy
- Migraines
- Hyperthyroidism
- Hypoxia
- Hypoglycemia
- CNS Infections
What types of medications are associated with psychosis?
- Analgesics
- Anticholinergics
- Anticonvulsants
- Antihistamines
- Antihypertensives
- Antimycrobials
- Antiparkinsonians
- Corticosteroids
- Muscle relaxants
- GI medications
- Antidepressants
- Chemotherapy
- Disulfiram
Psychosis can lead to these changes in functionality/behavior
- Social withdrawal
- Sleep disturbances
- Impaired memory
- Attention deficits
- Anxiety
- Decreased motivation
- Anhedonia
- Unusual/odd behavior
- Difficulty with ADLs
- Diminished sense of smell
- Decreased stress tolerance
- Increased sensory activity
This stage of HIV presents no AIDS defining illnesses and CD4 T-cell level is 14-28% with a cell count of 200-499
Stage II
This stage of HIV presents AIDS illnesses and CD4 T-cell level is less than 14% with a cell count <200
Stage III
This stage of HIV presents with HIV infection and AIDS illness and no info regarding CD4 T-cells
Stage IV
This stage of HIV presents no AIDS defining illnesses and CD4 T-cell level is 29% or higher and a cell count of 500 or higher
Stage 1
What is the goal of HIV management?
Keep viral load low and Medication load high
This enzyme converts HIV’s single stranded RNA into double stranded DNA
Reverse Transcriptase
What drug class prevents the HIV retrovirus from converting from single stranded RNA to double stranded DNA
- Nucleoside Reverse Transcriptase Inhibitors (NRTIs)
- Non-Nucleoside Reverse Transcriptase Inhibitors (NNRTIs)
This enzyme allows HIV DNA to infiltrate the nucleus of the CD4 t-cell
Integrase
What drug class prevents the HIV retrovirus DNA from infiltrating the nucleus of the CD4 T-cells
Integrase Inhibitors (IIs)
This HIV enzyme allows the protein strand to be broken
Protease
What drug class prevents the HIV enzyme protease from breaking protein strands
Protease Inhibitors (PIs)
What are the risk factors that can effect the rate of progression for AIDS?
- Frequent re-exposure to HIV
- Presence of other STDs
- Nutritional status
- Stress
- Non-adherence to medication protocol
What is the timeframe for acute HIV infection development after being infected?
Some within 4 weeks
What are the manifestations of acute HIV infection?
- Fever
- Night sweats
- Chills
- Headache
- Muscle aches
- Sore throat
- Rash
What are the immune system abnormalities that occur with poor CD4 T-cell function?
- Lymphocytopenia
- Increased production of incomplete/non-functional antibodies
- Abnormally functioning macrophages
What is the most common cause of death for those with HIV, other than AIDS?
Opportunistic infection
What is the timeframe from the beginning of HIV infection to the development of AIDS
Ranges from months to years
How is AIDS most commonly transmitted?
Male-to-Male sexual encounter
What are the modes of transmission for AIDS?
- Male-to-Male sexual encounter
- Exposure to semen/blood of infected individual
- Parenterally (needle stick, transfusion)
- Perinatally (infant exposure to blood/vaginal secretions or breast milk
Most new cases of HIV occur in which ethnic groups?
- African American
- Hispanic
What are the ABCs of safe sex to prevent HIV/AIDS?
A - Abstinence
B - Be faithful
C - Condom use
How is HIV most often sexually transmitted?
- Genital
- Anal
- Oral
Any mucous membranes exposed to infected semen, blood or vaginal secretions
Which body fluids can carry the HIV virus?
- Blood
- Semen
- Vaginal secretions
- Breast milk
- Amniotic fluid
- Urine
- Feces
- Saliva
- Tears
- CSF
- Lymph nodes
- Cervical cells
- Corneal tissue
- Brain tissue
HIV is more easily transmitted between these two types of individuals?
Infected male and uninfected female
What condition presents in HIV+ females?
Irregular menses
What condition presents in HIV+ males?
Low testosterone
What are the immunologic manifestations of AIDS?
- Low WBCs (CD4 ct <200)(CD4/CD8 ration <2)
- Hypergammaglobulinemia
- Opportunistic infections
- Lymphadenopathy
- Fatigue
What are the integumentary manifestations of AIDS?
- Dry skin
- Poor wound healing
- Skin lesions
- Night sweats
What are the respiratory manifestations of AIDS?
- Cough
- Shortness of breath
What are the GI manifestations of AIDS?
- Diarrhea
- Weight loss
- Nausea/Vomiting
What are the CNS manifestations of AIDS?
- Confusion
- Dementia
- Headache
- Fever
- Visual changes
- Memory changes
- Personality changes
- Pain
- Seizures
What are the opportunistic viral infections common with AIDS?
- Cytomegalovirus
- Herpes
- Varicella-zoster
What are the opportunistic bacterial infections common with AIDS?
- Mycobacterium avium
- TB
- Nocardiosis
What are the opportunistic fungal infections common with AIDS?
- Candidiasis
- Pneumonia
- Cryptococcosis
- Histoplasmosis
- Coccidioidomycosis
What are the opportunistic protozoal infections common with AIDS?
- Toxoplasmosis
- Cryptosporidosis
- Isosproiasis
- Microsporidosis
- Strongyloidiasis
- Giardiasis
What is the most common opportunistic infection for people with HIV?
Pneumocystis Jiroveci pneumonia (PCP)
What is the infection contracted through cat feces or ingesting undercooked meat?
Toxoplasmosis encephalitis
What is the infection that results in a loss of fluids of up to 15 to 20 L/day and ranges from mild diarrhea to severe wasting with electrolyte imbalance?
Cryptosporidiosis
Assess for unplanned weight loss of 5 pounds or more
What are the malignancies associated with weakened immune systems?
- Kaposi’s sarcoma
- Lymphoma
- HPV
What are the endocrine complications that may present with HIV?
- Gonadal dysfunction
- Decreased body muscle mass
- Decreased weight
- Decreased libido
- Decreased energy
- Fatigue
- Body shape changes (buffalo hump)(from PIs & NRTIs)
Which HIV drug causes higher incidence of type 1 diabetes and hyperlipidemia?
PIs
What is the normal ration of CD4:CD8 cells?
- 2:1
With HIV/AIDS CD4 levels decrease while CD8 levels remain normal
What is the normal WBC count
-5,000 to 10,000
With HIV/AIDS levels drop (often as low as 3500)
What should the diet be for a person with HIV/AIDS?
- High calorie
- High protein
- Drink 2-3 L/day
What happens to hematocrit and hemoglobin levels if shock is caused by poor clotting and hemorrhage?
Levels will decrease
What happens to hematocrit and hemoglobin levels if shock is caused by dehydration or fluid shift?
Levels will increase
What is the period of time which TIA symptoms typically resolve?
30-60 minutes
This is a sudden and periodic constriction of a cerebral artery and often follows subarachnoid hemorrhage or bleeding from an aneurysm or AVM rupture?
Vasospasm
The standard of practice for this type of stroke is to start two IV lines with non-dextrose isotonic saline
Ischemic stroke
