Lecture 9 - Neuro Flashcards
What is MS?
An autoimmune disease of the CNS - results the inflammatory demyelination of nerves in CNS, which disrupts nerve transition
What causes MS?
No exact cause known
–> Lifestyle, environmental, biological factors contribute
When is the typical onset of MS?
ages 20-50 (more specifically, 30-35)
Which gender is affected more by MS? What about geographic demographics?
Women (75%)
–> Canada, Northern USA, Northern and central Europe, Australia, New Zealand
What is the diagnostic process for MS?
Hx - S/S, family Hx
Neuro Assessment - Eyes and facial movement, reflexes, strength, sensation, coordination
MRI - Looking for abnormalities in brain and spinal cord
Lumbar Puncture/Spinal Tap - Examines fluid for increased levels of immunoglobulin and oligoclonal banding
What is clinically isolated syndrome?
Refers to an episode of neurological symptoms suggesting MS.
–> Often found using MRI to find evidence of abnormality in the brain and spinal cord
What is Relapsing-Remitting MS?
Characterized by unpredictable but clearly defined relapses during which new symptoms appear or existing ones get worse
–> Between relapse, recovery is complete or near complete to pre-relapse
–> Relapse lasts at least 48 hours and may g on for several months
What is a Pseudo-Relapse in MS?
When the body is fighting another infection or otherwise stressed and symptoms appear to mimic relapse (but relapse has not occurred)
What is the most common kind of MS?
RRMS
–> 85%
What is benign MS?
A subtype of RRMS
–> Remission after relapse is almost complete and there is only minimal disability after 10-15 cases
–> 10-15% of cases
What is aggressive/malignant MS?
Multiple relapses early in disease and rapid disability within 5 years of onset
–> Very rare
What scale is used to measure the progression of MS on life?
The Expanded Disability Status Scale (EDSS)
What are the symptoms of MS?
Invisible:
–> Fatigue, visual problems, paresthesia, cognitive impairment, bladder and bowel problems, pain, dizziness, depression and mood alterations, sexual dysfunction
Apparent:
–> Motor function changes (walking, weakness spasticity, tremor, drop foot), speech problems, lack of balance and coordination
What is the most common symptoms of MS?
Fatigue
–> 90% experience an overwhelming sense of tiredness, lack of energy, or feeling of exhaustion
What visual problems are seen in MS?
Optic Neuritis (most common)
–> Inflammation of optic nerve results in painful eye movements, blurring or graying of vision, or blindness in one eye
Nystagmus
–> Uncontrolled eye movement
Diplopia
–> Double vision caused by eye muscle weakness
Cognitive changes occur in what percent of people with MS?
50% have memory or recall problems
–> Person with MS may not be aware of this deficit even when its obvious to others
What are the three categories of medication for MS?
- Disease Modifying Therapies (DMTs)
- Relapse Management Medications (steroids)
- Symptom Management Medications
What is the purpose of disease-modifying therapies in MS?
Drugs that impact the underlying disease and target the inflammatory process in MS to
–> Reduce frequency and severity of relapses
–> Reduce number of lesions seen in MRI
–> Slow accumulation of disability
*available as injectable, oral, and infusion medication
What drugs are used for relapse management in MS?
High Dose Corticosteroids (usually 5 days)
–> Decreases severity and duration of relapse by reducing inflammation that occurs in CNS
What medications can be used for symptoms management of MS?
Drugs that help ease symptoms such as fatigue, bladder issues, spasticity, and pain
–> Immunomodulators
–> Antispasmodics
–> CNS stimulants
–> Anticholinergics
–> Antidepressants
–> Vit D
What non-pharmacological treatments can be used in MS?
Improve quality of Life
–> Exercise
–> Physio/OC
–> Rehabilitation
–> Massage
–> Stress Reduction Techniques
Recent research indicates that ___ is safe and beneficial for people with MS. It is now recognized as an important part of the overall care plan.
Physical activity
What are four important traits of stem cells?
Pluripotency
–> Can grow into different cell types
Self-Renewing
High Proliferation Potential
Transplantable
How did research into stem cell therapy begin for MS?
Research began when a pt with leukemia and MS had a stem cell transplant for leukemia and her MS improved
What is an autologous transplant?
Transplant of one’s own cells
What is an allogeneic transplant?
Transplantation of donor cells
What are seizures?
Uncontrolled, transient neuronal activity in the brain that interrupts normal function
What is the typical cause of seizure disorders by age?
First 6 Months
–> birth injury, congenital and metabolic disorders
2-20
–> Infection, trauma, genetic
20-30 years
–> Structural lesions (trauma, tumors, vascular disease)
After age of 50
–> cerebrovascular lesions and metastatic brain tumors
What is epilepsy? What age is it usually diagnosed by?
At least two spontaneous seizures in greater than 24 hours, caused by underlying chronic pathology
–> Most diagnosed by 18
What are the four phases of seizures?
Prodrome
–> signs or activities that precede the seizure
Aural
–> Sensory warning
Ictal
–> Full seizure
Postictal
–> Recovery
What are tonic-clonic seizures?
Characterized by loss of consciousness and memory of seizure. The body will stiffen for 10-20 seconds (tonic), and then extremities will jerk for 30-40 (clonic) seconds.
–> Cyanosis, salivation, cheek and tongue biting, and incontinence may accompany seizure.
What is status epilepticus?
A state of continuous seizure activity in which seizures occur in rapid succession and without return to consciousness between them.
–> Use of more energy than is available can result in permanent brain damage
Tonic-Clonic is most dangerous because can result is ventilatory insufficiency, hyperthermia, hypoxia, and dysrhythmias.
What diagnostic studies are doen for seizure disorders?
EEG
–> Only shows abnormalities
–> Some people without seizure disorders who abnormalities, and those with seizure disorders only show them when seizing
May also use CT, MRI for new-onset seizures to rule out abnormalities.
CBC, metabolic panel, liver and kidney studies, urinalysis
What should the nursing interventions be during a seizure?
Observe al details: lengths of seizure, preceding factors, data by phase.
Oxygenation
–> Airway patency, support head, turn onto side, o2 mask 6L
–> May require repositioning onto side, suctioning, or oxygen after seizure.
Assessment of level of understanding
What are the medication therapy goals with seizures?
Stabilization of the cell membrane and prevention of epileptic discharge
–> Monitor serum levels of medication
What can we give someone during status epilepticus to cease seizure activity?
IV benzodiazepines and anticonvulsants.
What are some seizure precautions?
Injury/Fall/Emergency Precautions
–> Pad side rails with flannel blankets
–> Ensure top rails are up
–> Ensure suction/O2 available
–> Bed at lowest position
What diet can be therapeutic for MS?
Diet high it Vit b12, C, D
Diet low in fat, with gluten-free, and lots of raw vegetables.
What patient teaching is necessary for MS?
Avoiding fatigue, extremes hot and cold, exposure to infections
Fiber for bowel regularity
Might need teaching of self-catheterization
What is Parkinson’s disease?
Disease of basal ganglia characterized by slowing down in the initiation and execution of movement
–> Increases muscle tone
–> Tremor as rest
–> Impaired gait
Unknown etiology
What is the etiology of Parkinsons?
Unknown etiology - Lewy bodies of unknown origin found in brain.
What are the classic manifestations of Parkinsons?
TRAP:
Tremor
Rigidity
Akinesia
Postural Instability
Akinesia of what kind is most prevalent in Parkinsons?
Akinesia is the absence of loss of voluntary muscle movement
–> Bradykinesia (slowness of movements) is especially evident in the loss of autonomic movements in Parkinsons
Other than TRAP, what other symptoms are seen in parksinsons?
–> Depression, anxiety, apathy
–> Fatigue, memory changed
–> pain
–> Sleep conditions, memory changes
–> Malnutrition, urinary retention, constipation, erectile dysfunction
What medications are used for Parkinsons?
Levodopa with Carbidopa (Sinimet)
–> Enhance release or supply of dopamine
Antiviral - unknown reason
Anticholinergics and antihistamines
–> Block effects of overactive cholinergic neurons in striatum
What are lifestyle changes that can help with Parkinsons
Promoting physical exercise and wellbeing
Using elevated toilet seats, avoiding buttons or things that can be difficult with compromised fine motor skills, promotion of safety.
What is Myasthenia Gravis? What does the disease process look like?
A chronic neuromuscular autoimmune disease caused by loss of ACH receptors necessary for muscles to contract
–> Ocular muscle weakness
–> Bulbar Muscle weakness
–> Skeletal muscle weakness
Some patients have short-term remissions and other have progressive involvement
How do we diagnose myasthenia gravis?
Diagnosis is based on clinical presentation - muscle weakness with repetitive movement
Confirmed by testing response to anticholinesterase drug Tensilon*
*textbook says this test is not done in North America as it has become obsolete, but the slides say it is still performed.
What surgical treatment is available for myasthenia gravis?
The thymus gland appears to enhance production of Ach receptor antibodies, so removing is results in improvement in most patients.
What pharmacological interventions are used for myasthenia gravis?
Anticholinesterase agents such as pyridostigmine bromide, neostigmine bromide
Corticosteroids - prednisone
Immunosuppressive agents - azathioprine, cyclophosphamide
How should those with myasthenia gravis change their eating and lifestyle habits?
Eating
–> Sit upright during and 1 hour after eating
–> Keep chin down when swallowing
Misc - coughing and deep breathing, suction at bedside.
Plan activities with rest periods and be aware the weakness will be greater at the end of the day.
What are absence seizures? Who do they affect?
Loss of awareness without the body dropping or convulsing.
–> Almost only seen in children and disappear by adolescence
Atypical versions may also present with eye blinking or jerking of the lips –> may continue into adulthood
What is a focal aware seizure?
Do not involve loss of consciousness and rarely last longer than 1 minute. May involve motor, sensory, or autonomic phenomena and are often focused in specific areas of the brain.
–> aka Jacksonian seizures
Antiseizure medications control seizures in what percentage of those with seizure disorders?
70%
What diagnostic tests are available for parkinsons?
No specific tests are available, diagnosis is based solely on history and clinical features.
–> Clinical diagnosis requires the presence of TRAP
Parkinsonian tremor is usually one that occurs during…
rest.
What kind of rigidity is seen in parkinsonism?
Resistance to passive motion and usually of jerky quality (cogwheel)
Sustained contraction results in soreness, achiness.
What kinds of postural instability are seen in parkinsons?
Patients feeling as though they are unable to stop themselves from falling forward or backward.
Pull test - causes patient to fall backward
What nutritional therapy can be helpful for those with parkinsons?
Malnutrition and constipation can result from poor nutrition
—> Appetizing and easy to chew and swallow foods
–> High fiber and fruit to reduce constipation
Six small meals a day can be less tiring the three large ones, account for ample time for eating. Food should be cut into bite-sized pieces.
Protein ingestion and B6 can impair levodopa absorption
Which food items can impair levodopa absorption and should thus be limited with parkinsons?
Protein and B6
How does myasthenia gravis present?
Chronic muscle fatigue, vision changes, droopy eyelids, weakness in extremities, impaired or slurred speech.
What is a myasthenic crisis?
An acute exacerbation of muscle weakness triggered by infection, surgery, emotional distress, pregnancy, exposure to some medications, or beginning of treatment with corticosteroids.
Major complications are respiratory muscle weakness.
What is a cardiovascular accident?
Loss of blood flow to brain results in cell death
What are the two kinds of strokes and what is their prevalence?
Ischemic - 85%
Hemorrhagic - 15%
What is an ischemic stroke?
When an embolus lodges in and occludes a cerebral artery.
–> Infarction + edema of the area supplied the the involved vessel
Sudden onset on symptoms
What is hemorrhagic stroke?
Results from intracerebral bleeding and has sudden onset of symptoms.
What are the symptoms of hemorrhagic stroke?
Neurological deficits, headache, N/V, decreased LoC, HTN
What is the primary cause of hemorrhagic stroke? When do they usually occur?
HTN - 1° cause
–> Usually occur during periods of activity
What are the non-modifiable risk factors for stroke?
Increased Age
More common in women
Ethnicity - Indigenous, African, South Asian heritage
Family + medical Hx
What are the modifiable risk factors for stroke?
HTN, heart disease, diabetes, oral contraceptive use, physical inactivity, obesity
What is a TIA? How long to they last?
Transient episode of neurological dysfunction caused by focal brain, spinal cord, or retinal ischemia without acute infarction of the brain.
Symptoms last less than an hour.
How can we prevent stroke in those that have had TIAs?
Antiplatelet medication are usually chosen to prevent stroke for those that have had a TIA
–> ASA
Statins can also be used.
What is aphasia?
Loss of understandings of and ability to communicate through language.
What is dysarthria?
Inability to articulate words - causes slowed or slurred speech.
Stroke can result in impairment of…
Mobility
Respiratory function
Swallowing + Gag reflex
Speech + communication
Elimination
Self-Care abilities
The following symptoms are indicative of which sided brain damage?
Spatial-perceptual deficit, tends to deny or minimize problems, rapid performance with short attention span.
Compulsive with safety concerns, and impaired judgement and time concepts.
Right-sided brain damage
–> We also might see left sided hemiplegia and neglect.
The following symptoms are indicative of which sided brain damage?
Slowed performance, overly cautious. Impaired right-left discrimination. Person will be aware of deficits and experience depression and anxiety
Impaired language and math comprehension.
Left-sided
–> Right-sided hemiplegia
Which side of the brain is responsible for spatial and time awareness?
Right side
Which side of the brain is responsible for right-left discrimination and language?
Left
Assessment findings for a stroke include…
Altered LoC, weakness, paresthesia.
Visual or speech disturbances
Respiratory distress, changes in HR
Unequal pupils, headache.
List the levels of GCS.
EYE OPENING
spontaneous - 4
to speech - 3
to pain - 2
none - 1
VERBAL RESPONSE
Ox3 - 5
Confused - 4
Inappropriate words - 3
Incomprehensible sounds - 2
No response - 1
MOTOR RESPONSE
Obeys commands - 6
localizes pain - 5
Withdrawal from pain - 4
Decorticate - 3
Decerebrate - 2
none - 1
What is decorticate posturing?
Arms flexed towards the core
What is decerebrate posturing?
Arms extended at sides.
What is mild, moderate, and severe GCS?
Mild - 13-15 (15 is normal)
Moderate - 9-12
Severe - 3-8
The purpose of diagnostic studies with a stroke is to determine what? How do we do this?
To confirm that it is a stroke and identify potential causes - CT scan primarily
Why would we perform an MRI on someone we suspect stroke on?
To determine the extent of brain injury
What are the goals for care during the acute phase of a stroke?
- Preserve life
- Prevent further brain damage
- Reduce disability
What is the initial collaborative care for acute stroke?
ABCs always
- Obtain CT
- Perform baseline labs
- Position head on midline
- If no symptoms of shock occur, elevate the hob 30°
What are priority nursing interventions with acute stroke?
- Airway patency
- Call the stroke team
- Remove dentures
- pulse oximetry + oxygenation
- IV Access w NS
- Maintain BP
- Seizure precautions
- Anticipate thrombolytic therapy for ischemic stroke
HTN is common right after stroke. What is the goal BP when administering drugs to lower it?
SBP - 140
MAP >75
Why is fluid and electrolyte balance so important following stroke?
Adequate hydration promotes perfusion and decreases further brain injury
What are the ongoing monitoring priorities with stroke?
LoC, sensory function, PERRLA, O2 sats, cardiac rhythm
How soon after ischemic stroke must tPA be administered?
within 3-4.5 hrs.
Aspirin for ischemic stroke should be given how soon afterwards?
24-48 hours
What surgical interventions are available for hemorrhagic stroke?
Immediate evacuation of aneurysm-induces hematomas (>3cm)
What surgical interventions are available for ischemic stroke?
Mechanical Embolus Removal in Cerebral Ischemia (MERCI)
How can we assess cerebellar function following stroke?
Asking pt to touch nose and nurse finger
Management of the respiratory system is a nursing priority. What are the relevant risks for someone following stroke?
Risk for atelectasis, aspiration pneumonia, airway obstruction
May req endotracheal intubation and mechanical vent.
What can prevent external hip rotation, hand contractures, and foot drop following stroke?
Trochanter rolls, hand cones, foot boards
Passive ROM is important
Following a stroke, a person should only be rolled onto the weak or paralyzed side for how long?
30 mins at a time
What is the most common GI issue post stroke? How can we prevent this?
Constipation
–> Treat with prophylactic fiber and stool softeners
Physical activity if possible
Should you use indwelling catheters to help with incontinence post stroke?
No, risk of infection.
Before a persons starts eating following a stroke, what should be assessed?
Swallowing, chewing, gag reflex, and risk of pocketing.
What is homonymous hemianopsia?
Blindness in same half of visual field
–> Common following stroke
Homonymous hemianopsia is common following stroke. What other visual changes are common?
Diplopia, ptosis, loss of corneal reflex
What is ptosis?
Drooping eyelid
What are the two kinds of ischemic stroke?
Thrombotic
–> Clot in BV d/t damage to vessel
Embolic
–> Clot formed elsewhere (usually heart) and lodges is BV in brain
What are some risk factors for embolic stroke?
Valvular diseases and a-fib
–> Can cause clot formation
What are the kinds of hemorrhagic stroke?
Intracerebral
–> Bleeding occurs directly into brain tissue itself
Subarachnoid
–> Bleeding in subarachnoid space between brain and skull
What are aneurisms?
Weak spots in BV walls that balloon out and can rupture
Which lab findings are expected with epilepsy?
Increased creatinine, BUN, and Liver function tests
Decreased BGL
