Neuro Flashcards
what is meningitis
- inflammation & swelling of the brain and spinal cord membranes
- leading to increased ICP
what are the causes of meningitis
- infection:
bacterial: Group B strep, E. coli, neisseria meningitidis (meningococcal), streptococcus pneumoniae, Hib
viral: EBV, enterovirus, adenovirus + mumps
- trauma
- autoimmune diseases (i.e. lupus)
Bacterial think = Bad news (most contagious)
S/S of meningitis
H-H-H
- H: headache & photophobia
- H: hard stiff neck “nuchal rigidity”
- H: high temp “fever”
S/S of meningitis in newborns
- high pitched or weak cry
- refusal to feed, V/D
- possible fever or hypothermia
- late signs: bulging fontanelle & nuchal rigidity
S/S of meningitis in infants <2yrs old
- high pitched cry
- bulging fontanelles at rest (report to HCP)
- irritability
- vomiting & poor feeding
- frequent seizures
- sunset eyes: sclera visible above the iris
infant complication - hydrocephalus
S/S of meningitis in peds age 2 - adolescence
- seizures (initial finding)
- nuchal rigidity
- positive Brudzinski’s sign (flexion of extremities with deliberate flexion of the child’s neck)
- positive Kernig’s sign (resistance or pain to extension of the leg from a flexed position)
- fever
- headache
- vomiting
- irritability -> ALOC
- petechiae: small round brown or purple colored spots (bacterial meningitis)
- non-blanching rash (neisseria meningococcal)
Kernig think “Krinkled knees”
Brudzinski “beach chair ski”
if hydrocephalus isn’t corrected quickly, what can it lead to?
- hearing & vision loss
- learning disability
- loss of coordination
- brain damage
- death
priority assessment is always fontanel
laboratory tests/diagnostics for meningitis
- test the CSF for infection
- blood cultures
abx after blood cultures
compare viral vs. bacterial meningitis difference in CSF
- viral: very clear
normal glucose - bacterial: bad cloudy
decreased glucose
elevated protein
both: elevated WBC count with bacterial > viral
nursing actions to prepare for lumbar puncture
- empty bladder
- topical anesthetic cream 45mins - 1 hr prior
- side-lying position with head flexed and knees drawn up to the chest
- sedation: fentanyl & midazolam if required
- pressure & elastic bandage applied to puncture site after needle removed
- monitor insertion site dressing for clear fluid - report
contraindications for lumbar puncture
- signs of increased ICP
- coagulopathy or thrombocytopenia
- local infection at puncture site
- hemodynamic or resp instability
what type of precaution is meningitis placed on
- droplet precautions: mask up & goggles
- isolation for minimum 24hrs after initiation of antibiotic therapy
nursing care for meningitis
- decrease environmental stimuli: minimize light & sound
- comfort: position without pillow, elevate HOB 30 degrees
- seizure precautions
what is the top priority for an infant <12 months old with meningitis
- give antibiotics before any assessments
treatment for meningitis
- correct fluid volume deficits then restrict until no evidence of increased ICP
- IV abx
- corticosteroids: dexamethasone (bacterial meningitis)
- teaching to get Hib vax
what are signs of increased ICP secondary to meningitis
newborns and infants:
- bulging fontanels
- increased head circumference
- high-pitched cry
- distended scalp veins bradycardia, resp changes
children:
- headache
- N/V
- diplopia
- seizures
- bradycardia, resp changes
nursing care for increased ICP secondary to meningitis
- avoid coughing, straining
- avoid bright lights & noise
differential diagnosis for meningitis
- encephalitis: inflammation of the brain (similar symptoms)
- sepsis
- brain abscess
- brain tumors
- Kawasaki disease
what is Guilllain-Barre syndrome
- immune system is trying to fight an infection
- proteins on the pathogen resemble parts of the nerves, the immune system mistakenly attacks the nerves
- immune system damages the myelin and axons
- nerves can’t send signals properly
- once immune attacks stops, nerves start to heal, however, axons may not completely recover
- autoimmune disorder
- acute inflammatory peripheral neuropathy & cranial nerves
- bilateral motor weakness
what are possible infection sources for Guillain-Barre syndrome
- infectious mononucleosis
- measles, mumps
- gastroenteritis
- Lyme disease
- EPV
- H. pylori
- cytomegalovirus
complications with Guillain-Barre syndrome
- resp distress/failure
- difficulty swalloing
- paralysis
when might Guillain-Barre syndrome start after the primary infection
typically 10 days after primary infection
S/S of Guillain-Barre syndrome
- bilateral muscle tenderness, paresthesia, cramps
- paralysis ascending from lower extremities
- diminished or absent deep tendon reflexes
- autonomic dysfunction: change in HR, BP fluctuations, GI (constipation, difficulty controlling bladder), SOB, may need MV/intubation
- cranial nerve involvement in severe cases: dysphagia, double vision, facial weakness
diagnostics for Guillain-Barre syndrome
- lumbar puncture: CSF
elevated protein
normal glucose
normal WBC - nerve conduction studies
- electromyography (EMG)
Treatment for Guillain-Barre syndrome
- plasmapheresis (plasma exchange): removes harmful antibodies from blood
- IVIG: provides healthy antibodies from donor plasma to neutralize the harmful ones
No corticosteroids
nursing care for Guillain-Barre syndrome
- resp support
- pain management: gabapentin/pregabalin
- nutritional support: feeding tube, NG tube
- GI support: urine catheter, stool softner
- DVT prophylaxis
pathophysiology of seizures
- abnormal, involuntary, excessive electrical discharges of neurons within the brain
- altered ions (Na, K, Ca) or release or neurotransmitters
causes of seizures
- anything that causes swelling or hypoxia: concussion, brain tumor, increased ICP
- lead poisoning
- tetanus, shigella, salmonella
- hypoglycemia
- fever
- drug or alcohol withdrawal
generalized vs. focal seizures
generalized is the whole brain, focal is partial
what are the types of partial and generalized seizures
- partial
simple
complex - generalized
absence (petit mal)
tonic-clonic (grand mal)
myoclonic
atonic
infantile spasms (west syndrome)
describe what tonic and clonic phase do during a seizure
- tonic phase:
tight & tense
piercing cry
cyanosis - clonic phase:
convulsions
incontinence
frothing - tonic-clonic: tight and convulsions
tonic-clonic seizure is also known as grand mal seizure
what are myoclonic seizures
- brief contractions
- involves only part of the body
- no postictal state
- might not lose consciousness
what are atonic seizures
- “drop attacks”
- muscle tone lost suddenly -> fall
- period of confusion follows
what are absent seizures
- “spaced out”
- day-dreaming, starying off into space
- brief interruptions of consciousness
what are the 2 types of partial “focal” seizures and compare them
- simple: fully conscious
- complex: impaired or loss of consciousness
what are typical signs of complex focal seizures
- lip smacking, biting, picking
- loss of consciousness
what are infantile spasms (west syndrome)
- sudden, brief symmetric muscle contractions
- possible eye deviation or nystagmus
- possible cry or irritability
- single event or clusters up to 150 seizures
what is given to treat infantile spasms (west syndrome)
adrenocorticotropic hormone (ACTH)
what are triggers for seizures
- sleep deprived
- strobe lights
- stimulants
- sugar or sodium low
what are the 4 stages of seizures and describe each stage
- prodromal phase: warning signs
changes in mood, behavior, or physical sensations - aura phase: first symptoms of a seizure
visual or auditory cues
most likely a tonic-clonic seizure - ictal phase: seizure
- postictal phase:
confusion, disorientation
headaches, sleepiness, tiredness
what should you assess during the postictal phase of a seizure
- assess LOC, neuro status, PERRLA, motor strength, sensation
- identify cause
what is status epilepticus? What is the priority?
- seizures lasting 5mins +
- repeated seizure in 30 mins
- priority: stop the seizure with IV or rectal benzodiazepines
grand mal (generalized) seizures are at risk for status epilepticus
what can untreated status epilepticus lead to
- hypoxia
- brain damage
- hyperprexia: high fever
- coma, death
what is the first line of drug for seizures
- IV or rectal benzodiazepine: lorazepam, diazepam
- SL ativan
- Intranasal midazolam
what is the second line of drug for seizures
IV phenytoin
diagnostics for seizures
- electroencephalogram (EEG): records electrical activity and can identify the origin of seizures - electrodes on scalp
- MRI/CT: structural issues
- toxicology screening
- LP: meningitis
patient education to prepare an EEG
- wash hair
- no caffeine or stimulants
- no seizure meds
- no sleep
- can eat before exam
Frequency of seizures that would be considered epilepsy
- at least 2 unprovoked seizures occuring greater than 24hrs apart
what are the treatments for epilepsy
- anti-seizure meds
- sx for partial epilepsy
focal resection, hemispherectomy (worst seizures), corpus callosotomy (separate the brain hemispheres) - implanted device: vagal nerve stimulator
- ketogenic diet
what are febrile seizures
- sudden spike in temperature 38.9-40C
- duration 15-20secs
treatment for febrile seizures
- give ibuprofen or acetaminophen q6hrs (can be interchangable)
- cool damp compress on forehead
call 911 if seizure lasts more than 5 mins
what is hydrocephalus
- excessive CSF -> increased ICP
- dilation of ventricles -> enlargement of skull
what are the 2 types of hydrocephalus
- communicating: impaired absorption of CSF
- non-communicating: obstruction of CSF flow
what are s/s of hydrocephalus in <2yrs old infant
- high pitched cry
- bulging fontanelles/eyeballs at rest
- irritablity and ALOC
- V/D & poor feeding
- frequent seizures
- sunset eyes “sclera visible above the iris”
- headache
- pupils sluggish - late
what is the priority assessment for hydrocephalus
- fontanel assessment
- head circumference > chest
what are the causes of hydrocephalus
- meningitis & infections
- tumors
- trauma: bleeding in the brain
diagnostics for hydrocephalus
- CT
- MRI
- ultrasound
treatment for hydrocephalus
meds another card
- ventriculoperitoneal shunt (VP): drains into temporary device - external ventricular drain (EVD) by gravity
- endoscopic third ventriculostomy: scope to create small hole in the floor of the third ventricle, hole allows CSF to flow into the subarachnoid space where it is reabsorbed naturally
what is important to watch for after VP shunt
- mechanical obstructions of shunt
- infection: sepsis, wound infection, meningitis (first couple of months)
- abx
medications for hydrocephalus/increased ICP
- seizures: phenytoin
- diuretics: mannitol
- swelling: dexamethasone, phenobarbital (sedation vacation, allow brain to rest)
what is crucial to monitor before and after sx from hydrocephalus
head circumference
what are nursing interventions for increased ICP for hydrocephalus
- I: immobilize head “C-spine”
- C: CO2 low (dilates vessels)
- P: flat first -> positioning 30-35 degrees of higher,
no flexion & bending of extremities
no sneezing, coughing, blowing nose
no valsalva maneuvers
hyperventilate (increase RR) pts to lower ICP
At what GCS score do you intube, what is considered good or bad score
- score ranges from 3-15
- 3: lowest score, 15: highest score
- less than 8 we intubate
any decrease in score should be reported
what is spina bifida
- infant’s spinal cord fails to develop properly
- neural tubes fail to fuse
- failure in formation of the vertebral neural archs
what are the 2 types of spina bifida
- spina bifida occulta: not visible
- spina bifida cystica: sac protrusion
types: meningocele, myelomeningocele
what is meningocele vs. myelomeningocele
- meningocele: meninges & spinal fluid
- myelomeningocele: meninges, spinal fluid, and nerves
s/s of spina bifida occulta
- small tuft of hair at the base of the spine
- saccral dimple or nevus birthmark
what are s/s of spina bifida
- sensory deficits
- neuro-muscular deficits: bowel/bladder function, paralysis
- extreme: vital changes
nursing actions for myelomeningocele pre-op
- cover area with moist sterile dressing
- use aseptic technique
- prone position
- I/Os
- neuro/motor assessments
reduce change of infection and damage to nerves, leakage of CSF
diagnostics for spina bifida
- amniocentesis: alpha-fetoprotein (AFP) test
- MRI/CT, ultrasound
risk factors for spina bifida
- maternal malnutrition: vitamin B-9 deficits (folic acid)
- genetics
- radiation
- anti-seizure meds: valproic acid, carbamazepine
treatment for spina bifida
- prenatal sx: reduces risk of further nerve damage; can lead to premature birth
- sx first 72hrs of life: close sac
what are good sources of folic acid for mothers
- green leafy vegetables
- black beans & rice
- peanut butter
- fortified cereals
- enriched bread
what is cerebral palsy
- permanent disorder of movement due to abnormal brain development
- random muscle spasms
what are the effects of random muscle spasms from cerebral palsy
- stiff muscle tones
- tremors
- involuntary motions with abnormal posturing
- lack of coordination
- difficulty speaking, talking, swallowing
- seizures, different cognitive function
- change in hearing/vision
what are early warning signs of cerebral palsy in infant/children
- no head control over 6 months old
- rigid muscles
- positive babinski sign (big toe up, other toes fan out) over 2 years old
management of cerebral palsy
- PT, braces, wheelchair, helmets
- speech therapy
- nutrition support
- seizure, spasm med
- ortho surgery
meds for cerebral palsy
- baclofen
