1
Q
Spinal Nerves
A
Cervical - 8 pairs Thoracic - 12 pairs Lumbar - 5 pairs Sacral - 5 pairs Coccyx - 1 pair
2
Q
Cranial Nerves
A
I - Olfactory II - Optic III - Oculomotor IV - Trochlear V - Trigeminal VI - Abducens VII - Facial VII - Acoustic or Vestibulocochlear IX - Glossopharyngeal X - Vagus XI - Accessory XII - Hypoglossal
“Some Say Money Matters But My Brother Says Big Brains Matter Most”
“Old Opie Occasionally Tries Trigonometry And Feels Very Gloomy, Vague and Hypoactive”
3
Q
Risk factors of Brain Attack
A
- Hypertension
- CAD
- CHF
- A-fib
- Hyperlipidemia
- Obesity
- Sickle Cell
- Diabetes
- BCP
- Smoking
- Cocaine abuse
- ETOH abuse
- High Hct
- Sedentary lifestyle
4
Q
General clinical manifestations of Brain Attack
A
- numbness, one sided weakness
- mental changes
- aphasia, dysphagia
- visual changes
- ataxia, dizziness
- severe headache
5
Q
Left sided CVA
A
- Right visual defect
- Right side paralysis
- Intellectual changes - memory
- Slow, cautious behavior
Left brain is more analytical, controlling math, logic and language
6
Q
Right sided CVA
A
- Left visual defects
- left sided paralysis
- spatial-perceptual changes
- decrease in attention
- impulsive behavior
- unaware of deficits
7
Q
Fast treatment for CVA
A
- t-PA
- Heparin
- Nursing measures:
- – raise HOB
- – Patent airway
- – Vital signs
- – Neuro checks
Long-term nursing measures:
- correct postioning
- exercise
- mobility
- ROM
- nutrition/vision
- be patient
- skin care
8
Q
Patient teaching for CVA
A
Promotion of self-care
- wide-grip utensils
- plate guards
- velcro
Environmental safety
- walker
- raised toilet seat
- non-skid mats
- hand-held shower
9
Q
Bell’s Palsy
A
- Disorder of the 7th cranial nerve
- age 15 - 60
- recovery 3-6 weeks
- Inflammation r/t viral infection, usually herpes simplex, herpes zoster, Epstein-barr
Risk factors: pregnancy, diabetes, URI
Diagnosis: EMG, CT
10
Q
Symptoms of Bell’s Palsy
A
- unilateral facial paralysis
- droop smile
- pain
- sound louder on affected side
- headache
- loss of taste
- changes in tear amount
11
Q
Treatments for Bell’s Palsy
A
- corticosteroids
- antivirals
- decompression surgery
- eye drops
- Vit B12, B6 and Zinc
12
Q
Guillain-Barre
A
- Inflammatory disorder where the immune system attacks the myelin sheath.
- Starts in legs to trunk, then arms and cranial nerves.
- No deep tendon reflex.
- acute period: 10-20 days
- 30% will need a ventilator
- Recover: 2 weeks to 24 months
- Risk factors: food poisoning, Hodgkin’s, HIV and Mono
Diagnosis: LP and EMG
13
Q
Symptoms of Guillain-Barre
A
weakness paresthesias difficulty with eye, facial movements severe LBP loss of B&B control bradycardia hypotension dyspnea
Complications:
5% die
80% no permanent damage
5-10% permanent damage
14
Q
Management of Guillain-Barre
A
plasmapheresis
immunoglobulins
15
Q
Seizure disorders and Epilepsy
A
Causes:
- birth injury
- undetermined
- vascular disease
- head trauma/tumor
- drug/ ETOH abuse
- infection
- genetics
16
Q
Tonic/Clonic (GrandMal)
A
- aura
- cry
- fall
- tonus (stiffening)
- clonus (jerkin)
- urine
- stool
Phases:
- Prodromal: early signs of seizure onset
- Aura: sensory warning
- Ictal: full seizure
- Postictal: recovery, very sleepy patient, muscle soreness, no memory of seizure
17
Q
Other generalized seizures
A
Typical Absence sz
- children, brief stare
Atypical absence sz
- stare and confusion
Myoclonic
- brief, cluster sz, in AM
Clonic
- jerks of same amplitude and decreasing frequency
Tonic
- children, loss of muscle tone, no clonicity
Atonic:
- sudden loss of tone
18
Q
Partial seizures
A
- Simple partial seizure: without impairment of consciousness
- Motor and/or sensory symptoms
- Can go into tonic/clonic
- Duration: 1 minute
- Complex partial sz: change in level of consciousness
- psychomotor sz
- sensory distortions
- Duration: average 2 min with postictal confusion
19
Q
Complications of Seizures
A
- Brain injury: glucose and O2 are depleted from the neurons. Build up of lactate -> acidosis -> hypoxia -> cell death.
- Status epilepticus: multiple seizures without regaining consciousness before the next. Cause: stopped meds.
- Psychosocial: limited driving, negative stigma, unemployment
20
Q
Management of Seizures
A
- heath history
- labs: FBS, electrolytes, BUM, creatinine, UA
- Skull xray, CT, MRI, EEG, LP
- Treat any underlying cause
- Medications, removal of precipitating factors and surgery
Valium 10 mg and Ativan 2-4mg
21
Q
Anticonvulsants
A
- prevents or reduces excessive discharge of neurons with seizure activity
- contraindications: alcoholism, DM, cardiac impairments, lactation
- side effects: drowsiness, sedation, gingival hyperplasia (big cause of stopping meds), anorexia, hyperglycemia, N/V
- teaching: life-long medication, take with food, no ETOH, must ok driving with MD, carry ID, must have drug levels drawn
22
Q
Nursing management during seizures
A
- protect the patient - NO mechanical restraint
- loosen constrictive clothing from neck
- head on pillow or lap - LATERAL position
- no object in mouth
- note time, record observations
In case of Status Epilepticus:
- IVP
- O2 (nasal cannula)
- suctioning
- mainline IVF - glucose
- external cooling
Do not remove dentures
23
Q
Nursing management after seizures
A
- level of consciousness assessment and reorientation as needed
- rest period of at least 30 minute with tonic/clonic
- assess for Todd’s paralysis (focal motor weakness)
- support family members
24
Q
Clinical manifestations of MS
A
- symptoms reflective of damage area, gradual onset of vague symptoms
- most common: visional changes, weakness (early in dz), unsteady gait, paresthesias, vertigo, elimination changes, cognitive changes, sexual dysfunction, fatigue
- up to 50% of pts are ambulatory 25 years after initial diagnosis
- No problems with pregnancy and lactation - but increase risk of exacerbation after pregnancy
25
Multiple Sclerosis
- autoimmune disease
- destruction of the CNS myelin
- 3rd common cause of disability in ages 15-60
- more common further away from equator
- usually white women - onset ages 20-40
- lesions noted on MRI
26
Symptoms and Drug Therapy for Multiple Sclerosis
- Spasticity: Valium -- SE: sedation
- Tremor: Inderal, Klonopin (sedation)
- Bladder: Ditropan - decreases urgency, incontinence -- SE: dry mouth
- Bowel: Metamucil, Colace
- Fatigue: Symmetrel - improves endurance
- Mood Changes: Elavil, Prozac
- Immune System: Copaxone, Betaserone (self administered subq)
27
Types of Multiple Sclerosis
- Relapsing-Remiitting
- Primary-Progressive
- Secondary-Progressive
- Progressive-Relapsing
Death from infections, immobility or other unrelated disease
28
Parkinson's Disease
- Motor dysfunction of triads: resting tremor, rigidity, and bradykinesia (slow movement)
- Caused by loss of nerve cells in the basal ganglia
- In 1% of people over 50 (men over 60 most common)
- Reduced level of dopamine
29
Five stages of Parkinson's Disease
- Flexion of affected arm: Patient leans towards unaffected side
- Slow shuffling gait
- Difficulty walking - uses supports to prevent falls
- Increasing weakness - Needs 1 assist
- Profound disability - may be WC bound
30
Triad of Symptoms of Parkinson's Disease
Tremor:
- 1st sign, distal part of extremity present at rest, diminishes with activity, pill rolling common
Rigidity:
- Increase muscular stiffness present throughout ROM. When tremor present - cogwheel rigidity.
Bradykinesia:
- Slowing of body movement - most difficult to treat. Affects automatic behaviors - blink, swallow, facial expressions, arm swinging
31
Nursing Care for Parkinson's Disease
Drug Therapy:
- Sinemet: increases levels of dopamine in the brain. Prevents peripheral breakdown of the levadopa and more will reach the brain. Lost of side effects!
Self-care promotion:
- Safety, swallowing, prevent constipation, and other complications of decreased mobility, change positions, use rocking method, lift toes, communication impairments, suction and nutrition
32
Myasthenia Gravis
- Abnormal fatigue of voluntary muscles caused by defect in neurotransmission
- autoimmune, amt of ACh recpetors decrease, which prevents ACh from attaching and stimulating contraction
- Young, 20-30 women
- genetic tendency
33
Clinical Manifestations of Myasthenia Gravis
- abnormal fatigue of voluntary muscles
- ocular: unable to close eyes
- diplopia Bulbar: speech and swallowing abnormalities
- choking, smile changes, neck and shoulder weakness
- trunk and limbs infrequently affected
- weakness increases during the day
- muscle stronger after rest period
- no sensory loss
- can have periods of remission
34
Nursing care for Myasthenia Gravis
Teaching:
- Do physical activities in the AM
- limited amout of physical activity around mealtiime
Drug Therapy:
- anticholinesterase
- immunosuppressant
- K
Drugs to avoid:
- Mycins
- Beta blockers
- Lithium
- Synthroid
- BCP
- Loop diuretics
Other therapies:
- Surgery: removal of thymus
- Plasma exchange: for acute treatment
- Crisis management: severe weakness with resp failure
- --Incidents: after URI, surgery, childbirth
- --Goal: maintain gas exchange and patent airway
- --Rule out cholinergic crisis (overdose of anticholinesterase)
35
Amyotrophic Lateral Sclerosis (ALS)
- Progressive spinal muscular atrophy
- age of onset 40-70
- death in 2-6 years (mean 3 years)
- unclear etiology
- genetic, men
- autoimmune
36
Clinical manifestations of ALS
- decrease in fine motor movement
- slow dragging gait
- tires easily with walking
- drooling
- difficulty chewing and speaking
- tongue contractions
- muscle cramps and stiffness
- respiratory failure is usual cause of death
- mind is unaffected (pt watch body die)
37
Nursing Care for ALS
Nutrition:
- lots of time to eat
- semisolid foods
- oral hygiene
- high fiber
- small, frequent meals
- avoid milk products
Mobility:
- ROM
- ADL's, avoid fatigue
Pulmonary:
- IS to Ventilator
- G-tube to prevent aspiration
Elimination:
- 64 oz fluid.
- avoid caffeine
- Bulk-forming meds
- indwelling cath
Rest & Comfort:
- ROM before bedtime to reduce cramping
- alternating pressure mattress
- elevate legs
Caregiver support:
- be a listener
- ALS support groups
38
Nursing Implications with Drug Therapy
- Dilantin: oral care, signs of toxicity, wean dose
- Phenobarbital & Mysoline: observe for drowsiness. -- SE: sedation, cognitive impairment, cheaper -- Wean dose
- Tegretol: wear dose, do not take with grapefruit juice. Watch cardiopulmonary status - Expensive
- Depakene/Depakote: liver function tests, SE: GI distress, tremor, alopecia, weight gain
- Valium & Ativan: IVP for status epilepticus. Do not use small hand veins - Atleast 5mg/min .. Pain with IM
NUB 350
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