Neuro Flashcards
What are seizures?
Paroxysmal, uncontrolled, excessive firing of hyperexcitable neurons in the brain.
Nerve cells continue to fire despite a determined “task” is completed… this continued firing cause parts of the body controlled by that nerve to move erratically
Normally neurons in the brain communicate with each other by rapid firing electrochemical signals
In a seizure, groups of neurons fire at the same time in one sudden burst
Define epilepsy.
Epilepsy is defined by 2 or more seizures experienced by a person
GABA or neurotransmitter imbalance or both
What are the causes or risk factors of seizures?
50% of seizure cases have no known cause—primary or idiopathic
Stroke
Hypoxemia of any cause, including vascular insufficiency (heart disease)
High Fever
Head injury
CNS infections
Metabolic and toxic conditions (e.g., kidney injury, hyponatremia, hypocalcemia, hypoglycemia, pesticide exposure)
Brain tumor
Drug and alcohol withdrawal
What are the pre and post phases of seizures?
Preictal- what occurred immediately before the seizure activity began?
Postictal- can lasts minutes to hours depending on type and severity of the seizure activity
Patient may be confused, lethargic, in pain, show debilities that will likely resolve once body recovers
What are partial seizures?
- No loss of consciousness
- Hand may shake or other single part of the body
- Mouth may twitch
- Lasts up to 90 seconds
- Usually has an aura before the seizure
Dizzy, smell, sound, vision, “unusual feeling”
What are Tonic-clonic (grand mal) seizures?
Entire cerebral cortex is involved
Aura present
- Irritability and tension may precede, most begin without warning
Tonic phase and clonic phase
- Generalized tonic extension of extremities lasting a few seconds
- Followed by clonic rhythmic movements and prolonged postictal confusion
Doesn’t feel, see, or remember anything during the seizure
Lasts 2-5 minutes
How do seizures differ in older adults?
Complex partial is most common type
Symptoms may appear similar to dementia or psychosis
New onset is typically associated with hypertension, diabetes, dementia, stroke, and recent brain injury
What is status epilepticus?
-Prolonged or frequent seizures
Most often a results of abrupt stop in AED medication
May also be caused by untreated or inadequately treated conditions
-A single seizure lasting more than 5 minutes
-Intermittent seizure activity lasting 30 minutes or more
Recovery between seizures is incomplete
Medical Emergency
10% mortality rate
Typically any seizure lasting longer than 5 minutes will NOT stop spontaneously
Intervene immediately with IV Lorazepam/Diazepam, then IV AED
What are seizure precautions?
Oxygen Suction equipment Airway Iv access Side rails up and padded
What is seizure “first aid”?
- Time the seizure
- Speak calmly
- Don’t grab or hold
- Explain to others
- Block hazards
What should you do while the seizure is occurring?
Protect patient from injury
- Move furniture
- Place something under head if not in bed
- Turn patient on side in case of foaming in mouth or vomiting
- Do not restrain patient
Maintain airway
- Use oral suction as needed
- NEVER force anything into the patient’s mouth
Observe!
- Length
- Body parts involved
- Incontinence
- Any sounds patient may make
After seizure is over
- vital signs
- neuro checks
- allow for rest
- keep in side lying position
What is the medication management for seizures?
Diazepam or Lorazepam Diastat Phenytoin Fosphenytoin Valproate Carbamazepine Lamotrigine Levetiracetam
What considerations for discharge for a pt with seizures/epilepsy?
Continuing medications Avoid alcohol and excessive fatigue Follow up appointments Family member is aware of interventions if a seizure occurs Medical bracelet NO DRIVING Social implications Can the patient still work?
How is epilepsy diagnosed?
- Epilepsy is diagnosed by taking a careful history and ruling out secondary causes first
- MRI is essential to helping detect causes
- Complete cessation of seizures using a single AED without side effects is the goal of therapy
- Failure of 2 AEDs suggests that the diagnosis may be incorrect or that the patient has intractable epilepsy requiring a referral to a neurologist and/or neurosurgeon
What is Guillain-Barre?
Demyelination of peripheral nerves
Commonly results from immune response following febrile illness or vaccine (flu)
There are some reports of this response following the covid vaccine
Symptoms
-Initial muscle weakness and pain
- Ascending paralysis
- Autonomic dysfunction
What is the plan of care for Guillain-Barre?
Priorities -Respiratory care -Pain management and paresthesias -Skin and mobility -Nutritional needs Involvement of family Education -Medical treatments -Plasmapheresis -IVIG - Intravenous Immunoglobulin
What is a stroke?
- A sudden loss of brain function resulting from disruption of the blood supply to a part of the brain and depriving oxygen delivery
- This is the 3rd leading cause of death and disability in the United States
- Ischemic vs hemorrhagic
- –> MCA is most common location
What are the different types of strokes?
- Hemorrhagic – the brain bleeds due to a rupture in the blood vessel
- This can be traumatic or spontaneous
- SAH vs ICH
- Can be from ruptured aneurysm
- Uncontrolled blood pressure
- “Worst headache of their life”
– Embolic vs Thrombotic
(I) Embolic – a clot has blocked the flow of blood through the vessels in the brain
(II) Thrombotic – an occluded/narrowed vessel, usually due to plaque build up – the blood cannot travel through to reach all areas of the brain
(III) TIA - mini stroke (transient ischemic attack)
Used as a warning that a major stroke is coming if not properly treated
Always ischemic
Symptoms usually resolve within a short amount of time.
What are the risk factors for stroke?
Hypertension – may be med induced Heart disease – Afib and mitral valve Diabetes Sleep apnea Cholesterol Sedentary lifestyle smoking Substance abuse Hormone replacement and birth control Obesity ethnicity Trauma/falls
What are the symptoms of left-sided stroke?
Aphasia and Agraphia Memory deficit Inability to recognize words or letters Anxiety Quick to anger Slow to respond
What are the symptoms of right-sided stroke?
Personality changes Disorientation or inability to recognize faces Loss of depth perception Impulsive, unaware of deficits Poor judgment Loss of hearing and tone variations
What are the general symptoms of stroke?
Frontal lobe effects emotional and personality changes
Broca’s area = expressive aphasia
Wernicke’s area = receptive aphasia
Long term may develop vascular dementia, especially when more than one stroke occurs
What does the acronym “FAST” stand for?
Time is brain so act fast
Face - has their face changed?
Arms - can they lift both arms?
Speech - slurred? Can they understand you?
Time. is critical
- Last known “well” time
- Time to call 911
What are the stroke levels?
Level 1 - 0-3.5 hours Level 2 - 3.5-6 hours Level 3 - Anyone greater than 6 hours
what is the NIH scale?
Universal assessment of the severity of deficits
Used to test mobility, strength, vision, and cognitive ability
“FLEAS GIVE ME A STROKE”
Face, Loc, eyes, arms/legs, speech
Describe the flow of care for stroke.
What tests/labs will be done for stroke patients?
CT – rule out bleed MRI – confirm CVA and location Carotid US to look for blockages --> endocardectomy Echo – looking for heart damage --> Ejection fraction Lipid panel and Hgb A1C Will be discharged on Aspirin or Clopidogrel and Cholesterol medication based on labs and initial cause Screen for other comorbidities
What are the treatment option for stroke?
TPA – time sensitive
Embolectomy
Place on telemetry
Strictly monitor ICP and BP
Treat the cause – angioplasty, carotid endoarterectomy, medication management of DM, Cholesterol, HTN
PT/OT/ST
- Swallow study
- Nutritional support if difficulty swallowing
Surgery if it is hemorrhagic to evacuate blood and discontinue all blood thinners
- Monitor for vasospasm - - tx with Nimodipine (Nimotop)
What is TPA?
TPA- tissue plasminogen activator
Only used on Level 1 Requires informed consent Weight based dosing Strict monitoring for 24-48 hours after given Restricted for - Older than 80 - On anticoagulant - NIH score greater than 22 - History of both stroke and diabetes
How can clots be prevented?
SCD machine
Aspirin
Warfarin
Heparin/Enoxeparin
Clopidogrel (Plavix)
Dipyridamole (Aggrenox) - IR asa and er dipyridamole
Apixaban (Eliquis) - no lab monitoring and does have some restrictions with Afib types
What does rehabilitation look like for stroke patients?
Increase mobility and strength
Learn alternate ways to complete ADLs
Alternative communication and eating needs
Determine how much assistance patient will need at discharge
What education is important for stroke patients?x`
Risk factors Life style changes S/S to look for – FAST Include family in education Available support groups – AHA and stroke folks
What is dementia?
Must have at least 2 of the following impairments to receive diagnosis of dementia
- Memory
- Communication and language
- Attention span or ability to focus
- Reasoning and judgment
- Visual perception
What are the types of dementia?
- Vascular dementia - Vascular dementia for patients with any chronic disease process cause vascular changes in the brain
Stroke
DM
Heart disease - Drug-induced dementia
Long term drug use or overdose
Exposure to environmental toxins such as lead
What is Alzheimer’s Disease?
A form of dementia - Accounts for 50% of dementia cases
Effects women more than men
Decreases ability to learn new information
Impairs memory
Decreased language and communication
Decreased attention span
Begin to forget how to perform basic ADLs safely and effectively
How is Alzheimer’s diagnosed?
Typically a rule out diagnosis… we have ruled out all other possibilities
Autopsy is only definitive way to diagnose
- Neurofibrillary tangles and neuritic plaques
Genetic tests - APOE4
Amyloid beta protein precursor (BPPs)
Obtain patient and family history
- Risk factors include age, gender, and family history
- TBI or repeated Head trauma, herpes virus exposure, down syndrome, and high level exposures to zinc and copper?
- African American and hispanic populations
Mini Mental State Exam - score of 5 or lower
What would you find on assessment with Alzheimer’s?
Speed of information processing Difficulty following directions Decreased attention and concentration Forgets daily activities Short term memory loss Communication – apraxia, aphasia, anomia, and agnosia - May not be able to tell you when something is wrong but will have a behavioral change Lost easily Functional decline Tactile changes Wandering Poor judgment
What is the treatment for Alzheimer’s?
NO CURE
Death is usually associated with complications of immobility
Symptom management
Medication options:
Donepezil (Aricept) Rivastigmine (Exelon) Memantine (Namenda) Antidepressants - Avoid amitriptyline (Elavil) - Paroxetine and sertraline Antipsychotics should be avoided
Describe the nursing management for Alzheimer’s.
Safety/Airway Don't try to orient (late stage) short directions routines familiar objects Meds (BEERS list) Delirium - assess/high risk mobility/ADLs Sundowning - end of life planning realistic expectations Safe to go home? redirection/distraction community resources safe return/gps MPOA nutrition
Maintain safety and airway Attempting to orient patient is not main goal give 1 short direction at a time and time to respond Keep consistent routines Provide familiar objects Avoid overmedicating and BEERS list Delirium assessment, high risk patients Assist with mobility/ADL management Sundowning – bed alarms, sitters, etc Redirection and distraction activities Breaks between activities Optimize nutritional intake Family/Caregiver support Written reminders Medication box End of life planning Living will, MPOA Set goals for daily life and realistic expectations Is the patient safe to go home (table 42-2) Community resources Safe Return Program and/or GPS
What is Parkinson’s Disease?
Movement disorder
- A progressive neurologic disorder resulting from degeneration of basal ganglia in the cerebellum
- 2nd most common neurologic disease in elderly
- Most commonly develops after age 50
Describe the patho behind Parkinson’s Disease.
Dopamine is an essential part of neuromuscular function and is excreted by the basal ganglia
Decreases in dopamine diminishes normal neuromuscular function and control
- Most persons will lose 50% of their dopamine before noticing the symptoms
Primary cause may be hereditary or have no known cause
Secondary may be related to other neurological disorders, drugs, and toxins
Progressively worsens over many years until death… death often due to pneumonia or other infection r/t immobility
What would you find on assessment for Parkinson’s?
4 Cardinal signs 1. Tremor… this is an early sign 2. Bradykinesia or akinesia 3. Decreased muscle tone and rigidity (cogwheel rigidity) 4. Postural instability (later sign) Additionally - Micrographia - Hypophonic dysarthria - Shuffling steps - Infrequent eye blinking - Diminished facial expression
what additional symptoms develop throughout the disease process of Parkinson’s?
Fatigue Stooped posture Mask like face and muffled voice Dysphagia Constipation Othostatic hypotension– due to reduction in sympathetic nervous system Drooling and nocturia Depression and/or withdrawal RLS RBD
How is Parkinson’s diagnosed?
Clinical symptoms r/o alternatives Family history Age of symptom onset Evaluation of non-motor symptoms that are occurring too DaTscan
What medications can be used for Parkinson’s?
Motor symptoms - Levodopa/Carbidopa--Duopa Dopamine Agonists - Ropinirole - Pramipexole Benztropine(Cogentin)s Selegiline
Non-Motor symptoms
- Antidepressants-Escitalopram
- Antianxiety-Buspirone
- Scopolamine/botox
- Donepezil/Memantine
- Domperidone
What are the treatment options for Parkinson’s?
NO CURE!!!!
Symptom management and provide support
Medications
Duopa - pump provides up to 16 hours of continuous carbidopa/levodopa infusion, gel direct to intestines
DBS - deep brain stimulation, device implanted in chest to deliver electrical stimulation in areas of brain that control movement
Pallidotomy - surgical procedure which involves destroying a tiny area in a part of the brain called the Globus Pallidus interna (GPi or pallidum). (Bc it is overactive and this can help with rigidity and tremors
Drug holidays
Describe the nursing management of Parkinson’s.
Goal is to preserve mobility, cognition, and quality of life
SAFETY
Exercise
Maintain airway
Manage diet to appropriate consistency and assist with feedings
- High protein and high calorie foods and use of supplements
Allow extra time for patient to respond
Provide alternative communication methods
ADL function
Monitor for cognitive changes
Avoid naps and caffeine
Patient and family education
Home management and safety
Support for coping
Long term planning
What are the most important things to remember about Parkinson’s?
Parkinson disease has 4 major signs: resting tremor, cogwheel rigidity, bradykinesia, and postural instability
Levodopa is most effective medication for treatment of symptoms
There are motor, cognitive, and emotional/behavioral consequences to this disease
A careful history should always be taken to determine primary or secondary diagnosis
Avoid use of typical antipsychotics and reglan/metoclopramide
What is the As of left-sided stroke (mnemonic)?
aphasia agraphia ABCDs (can't recognized words/letters) anger anxiety amnesia (memory deficits) awkward pauses (slowed responses)
What are the Ds of right-sided stroke (mnemonic)?
Dick (personality changes) disorientation (incl recognizing faces) depth perception decisions daredevils (poor judgment/impulsivity) deaf (loss of hearing and tone variations)
