adults exam 4

what is the purpose of a cerebral angiogram

done in order to visualize the cerebral blood vessels

what are the indications for cerebral angiogram

to identify aneurysms, defects, obstructions, or vascular malformations

what must be assessed prior to cerebral angiogram

consent, shell fish allergy due to contrast dye, any anticoagulant use, BUN/creatinine to assess kidney function in order to excrete dye

how is a cerebral angiogram preformed

catheter inserted into groin or neck, use iodine, need to hold still, monitor pulses, will use fluoroscopy and x rays to take pictures after dye is injected

what are the important post procedure points with cerebral angiograms

lay flat in bed for 12-14 hours, monitor puncture site every hour, if bleeding hold pressure, neuro circulatory checks on lower extremities, whatever leg was used immobilize puncture site for 6-8 hours, force fluids after to flush out dye

what is the purpose of a CAT (cerebral CT) scan

with other without dye, done to visualize components in brain + head, painless

what are the indications for a CAT scan

see if hemorrhage, visualize an infarction or stroke abscess or tumor in cerebral cavity

what are the important pre procedure points with a CAT scan

educate patient that if contrast dye is used they may feel a flush or warm face, metallic taste in mouth, consent, shellfish or iodine allergies

what should you do post CAT scan

encourage fluids to flush out dye

what is the purpose of an electroencephalography (EEG)

painless procedure to record electrical activity of brain

what are the indications for an EEG

seizures

what must happen prior to an EEG

pt may need to stay awake night before, no caffeine or stimulants 24 hours prior, no anti seizure or stimulant meds 24-48 hours prior

how is an EEG preformed

takes about 1 hour, electrodes placed on scalp, may be asked to hyperventilate for 3-4 minutes to increase electrical activity or bright light exposure

what happens post procedure with an EEG

help remove paste from hair and get electrodes off, administer anti seizure meds and watch for seizure activity

what is the purpose of the Glasgow coma scale

determines neurological function and level of consciousness in a numeric scale

what are the indications for the Glasgow coma scale

patients with head injuries, brain tumors, or encephalitis

what are the categories of the Glasgow coma scale

best eye response (1-4), best verbal response (1-5), best motor response (1-6)

what is the purpose of a lumbar puncture

needle inserted to obtain specimen of cerebral spinal fluid, relieve pressure, or inject meds like chemo

why is informed consent important with a lumbar puncture

rare, but serious risk of brain herniation if there is increased intracranial pressure

what are the indications for lumbar puncture

MS, meningitis, infections, cancers

what happens pre procedure with a lumbar puncture

help patient void prior and get into position

how is a lumbar puncture preformed

place in lateral recumbent metal at edge of bed, position so spine is stretched, local anesthetic used, physician can use monometer to test procedure of CSF

what is important to monitor after a lumbar puncture

monitor puncture site, neuro assess every 15-30 minutes until stable, lay flat for several hours afterwords, increase fluids to 3000 mL, if headache can give oral analgesic, if persists dr can do epidural blood patch to seal hole, monitor for bleeding or drainage

what is the purpose of an MRI

use magnets to visualize cross sectional images of head

what are the indications of an MRI

need to discriminate soft tissue from tumor or bone

what is important preprocedure with an MRI

assess shellfish/iodine allergy due to contrast dye, remove all jewelry, NPO 4-8 hours if getting sedation due to claustrophobia, assess for any metal implants like pacemaker

what is the purpose of intracranial pressure monitoring

device inserted into cranium that records pressure and is connected to monitor to show pressure waveforms

what are the indications for intracranial pressure monitoring

comatose pt in ICU with head injury

what happens pre procedure with intracranial pressure monitoring

head shaved and cleansed

how is intracranial pressure monitoring preformed

ventriculostomy; intraventricular fluid filled catheter inserted into ventricles through burr holes, subarachnoid screw or bolt placed. epidural or subdural fibrotic sensor; through burr hole and less invasive

what is important post intracranial pressure monitoring

serious life threatening risk for infection, monitor site, cover with sterile dressing + always preform sterile technique, watch for signs of increased intracranial pressure on monitor (greater than 15 mmHg), vital signs every hour

damage to nerves related to long term high glucose and low insulin

diabetic neuropathy

what are the different types of diabetic neuropathy

peripheral- most common in lower extremities then upper; can lead to ulcers

autonomic- all the nerves

proximal- thigh, hips, butt, and legs, one area but bilaterally

focal- damage specific nerve in face, torso, and legs

what are the symptoms of diabetic neuropathy

burning and stabbing pain, numbness, tingling, may cause safety issues and functional impairments

what are the resulting issues from diabetic neuropathy

balance, ability to recognize pain, ability to handle ADL tasks which require strength and dexterity

what is the treatment for diabetic neuropathy

long term control of blood glucose most important to diminish damage to the nerves

what medications are used for diabetic neuropathy

anticonvulsants (gabapentin, pregabalin), antidepressants, topical treatment (capsaicin) for focal neuropathy, lidocaine injection, vitamin supplements

chronic, degenerative motor system disorder caused by the loss of dopamine producing brain cells

parkinson’s disease

what are the clinical manifestations of parkinson’s disease

tremor at rest, rigidity/stiffness, bradykinesia (slow movement), postural instability, mask like face, shuffling gait, pill rolling tremor in fingers, insomnia, depression/anxiety/Lewy body dementia, weakness, autonomic dysfunction, slow speech

what is used to diagnose parkinson’s

neuro exam, unified parkinson’s disease rating scale, and levodopa test (check UPDRS, take levodopa, check UPDRS again)

what is the treatment for parkinson’s disease

carbidopa-levidopa; take 1 hour before or 2 hours after meals, evenly spaced, cam cause dyskinesia, N/V, dizziness, hypotension, can cause on/off response causing mobile/active one moment then slow/rigid the next

what other medications supplement carbidopa-levidopa in parkinson’s treatment

anticholinergics and antihistamines for tremor/rigidity, dopamine agonists, antiviral drug (amantadine), MAO-B inhibitors, COMT inhibitors

what are the complications from parkinson’s disease

parkinsonian crisis-severe W/D from meds or emotional upset (anxiety, sweating, tachycardia, tachypnea)

aspiration pneumonia, altered cognition, falls

what are the patient education points with parkinson’s disease

prevent constipation by increasing fluids and fiber, support mobility by encouraging exercise, ROM, good posture, rest periods, extra time for ADLs, home safety, elevated toilet seat, hand rails, velcro vs. buttons, reduce stress

what are other treatment options for parkinson’s disease

deep brain stimulation (implanted electrical device stops tremor), stereotactic palliodotomy (surgeon destroys brain tissue that causes tremor, mostly replaced by DBS), controversial= fetal tissue transplant and stem cells

a spouse of a husband who has parkinson’s explains to you that her husband experiences episodes while walking where he freezes and can’t move. she asks what can be done to help with these types of episodes to prevent injury. select all that apply

a. have the husband try to change the direction of movement by moving in the opposite direction when the freeze ups occur

b, use a cane with a laster point while walking

c. have the husband try to push through the freeze ups

d. encourage the husband to consciously life the legs while walking

a., c., d.

you’re caring for a patient with parkinson’s disease who has tremors. select the option that is incorrect about tremors experienced in this disease.

a. the tremors are most likely to occur with purposeful movements

b. a common term used to describe the tremors in the hands and fingers is called pill rolling

c. tremors are one of the most common signs of parkinsons

d. tremors in this disease can occur in the hands, fingers, arms, legs, and even the lips and tongue

a.

youre providing diet education to a patient with parkinson’s disease. which statement below demonstrates the patient understands your teaching? select all that apply

a. I will limit foods high in fiber like fruits and vegetables

b. I will be sure to drink 2 L of fluid per day

c. it is very common for me to experience diarrhea with this disease

d. I will avoid taking carbidopa/levodopa with a protein rich meal

b., d.

chronic demyelinating disease producing plaques on the myelin sheath of neurons in the CNS

multiple sclerosis

who most commonly gets MS

onset occurs between 25-35 y.o women, caucasian living in colder climates of North America and Europe

what are the 4 typical courses of MS

progressive relapsing (steady decline since onset with super-impacted attacks), secondary progressive (initial relapsing that suddenly begins to have decline without periods of remission), primary progressive (steady increase in disability without attacks), relapsing remitting (most common, unpredictable attacks which may or may not leave permanent deficits followed by periods of remission)

what are the clinical manifestations of MS

fatigue, visual disturbances, dysarthria (trouble speaking), ataxia (impaired coordination), spasticity, muscle weakness, sensory changes, pain, paresthesia, bladder/bowel dysfunction, sexual dysfunction, dysphagia, mood changes, cognitive impairment

MS is diagnosed by — of other disorders

exclusion

what are the pharmacological treatments of MS

immune suppressants and modulators, interferon beta (sc every other day), corticosteroids, glatiramer (remitting relapsing MS- daily SQ), azathioprine, cyclosporine

what are the symptomatic treatments for MS

antispasmotics- baclofen, tizanidine

anticholinergics for bladder- oxybutynin

clonazepam for anxiety/tremor

what are the non pharmacologic treatments for MS

exercise and ROM to minimize contractures and spasticity; eye patches for diplopia, communication boards, refer to speech therapy for dysphagia, energy conservation, skin and falls prevention

which finding below represents a positive Romberg sign in a patient with MS?

a. the patient reports dark spots in the visual fields during the confrontation visual field test

b. when the patient closes the eyes and stands with their feet together they start to lose their balance and sway back and forth

c. the patient’s sign and symptoms increase when exposed to hot temperatures

d. the patient reports an electric shock feeling when the head and neck are moved downward

b.

a patient is receiving interferon beta for treatment of multiple sclerosis. as the nurse you will stress the importance of?

a. physical exercise to improve fatigue

b. low fat diet

c. hand hygiene and avoiding infection

d. reporting ideation of suicide

c.

what is the most common cause for generalized paralysis from virus such as mono, cold/flu, can be triggered by flu vaccine

Guillain-barre

an acute inflammatory demyelinating polyneuropathy affecting the peripheral nervous system (temporary)

Guillain-barre

what are the hallmarks of guillain-barre

characteristic ascending weakness, maximum deficit within 4 weeks, can involve paralysis of respiratory system, 3 phases (initial/acute, plateau, recovery), usual recover within 6 months and up to 2 years, excellent prognosis

how is guillain-barre diagnoses

history and clinical presentation, CSF examination, EMG

what is the medical treatment for guillain-barre

considered a medical emergency, focus of therapy is supportive care, plasmapheresis, IVIG to reduce antibodies

what are the nursing management points with guillain-barre

vital signs, respiratory and swallowing assessments, I&O’s (SIADH in 26% patients- hyponatremia + hypoosmolarity), mobility, pain, preventing complications

autoimmune disease relating to loss of acetylcholine receptors in the post-synaptic neurons of the neuromuscular junction

myasthenia-gravis

what is the hallmark sign of myasthenia-gravis

muscle weakness that increases during periods of activity and improves after periods of rest

what are the clinical manifestations of myasthenia-gravis

weakness in muscles that control eye and eyelid movement, slurred speech, swallowing, respiratory dysfunction, fatigue

how is myasthenia-gravis diagnosed

blood test (presence of immune molecules or acetylcholine receptor antibodies), edriophonium (tensilon) test (prevents ACH breakdown-have atropine sulfate on hand), nerve conduction test, EMG

what are the treatments for myasthenia-gravis

anticholinesterase agents (pyridostigmine and neostigmine, Q3h), immunosuppressive drugs (prednisone, azathioprine if prednisone ineffective), thymectomy, plasmapheriesis, intravenous immune globulin (IVIG)

what are the complications from myasthenia-gravis

myasthenia crisis (triggered by infection, fever, respiratory weakness- increase medication), cholinergic crisis (over medicated, abdominal cramps, N/V/D, hypotension-give atropine)

which meal option would be the most appropriate for a patient with myasthenia-gravis?

a. roasted potatoes and cubed steak

b. hamburger with baked fries

c. clam chowder with mashed potatoes

d. fresh veggie tray with sliced cheese cubes

c.

what is amyotropic lateral sclerosis also known as

lou gherigs disease

most common of motor neuron diseases, tends to occur in middle age (male>female), fatal disease (2-5 years), involves degeneration of anterior horn cells and corticospinal tracts

amyotropic lateral sclerosis

what are the clinical manifestations of amyotropic lateral sclerosis

progressive muscle weakness, fasciculations/spasms and cramping of muscles, impairment of use of arms/legs, thick speech and difficulty projecting voice, SOB, difficulty breathing/swallowing, drooling; usually progressives from upper extremities to shoulders, trunk and neck with lower extremities affected later

what are the treatments for amyotropic lateral sclerosis

no cure, supportive therapy only. riluzole extends life by a few months (hepatotoxic-no alcohol)

what are the medications to control symptoms in amyotropic lateral sclerosis

baclofen, diazepam for spasticity, pain control, PEG tubes with TF once they cannot swallow

in pts with amyotropic lateral sclerosis, there will eventually be a need for mechanical ventilation. what allows living months or years beyond respiratory failure

tracheostomy invasive ventilation

sudden pain in any area innervated by 5th cranial nerve branch, shooting/stabbing/burning pain, may have involuntary contraction of facial muscle or eye twitching, occurs more as people age, can coexist with MS patients

trigeminal neuralgia

what are the treatments for trigeminal neuralgia

anti-seizure meds, gabapentin and baclofen for nerve pain, surgical resection possible

unilateral inflammation of the 7th cranial nerve (facial) causing weakness or paralysis of one side of face, usually in people under 45, may also have speech or chewing difficulties/facial droop, may be mistaken for stroke, spontaneous recovery in 3-5 weeks

bell’s palsy

what is the treatment for bells palsy

corticosteroids and analgesics

loss of intellectual ability with impairment severe enough to interfere with social or occupational functioning. loss of memory, reasoning, judgment, and language

dementia

what are the possible causes of dementia

brain hypoxia, reduced blood flow due to stroke, drugs

what must be ruled out before a dementia diagnosis

delirium

what is the most common type of dementia

alzheimers

dementia risk increases with advancing —-

age

what type of dementia is due to stroke

multi-infarct or vascular

what type of dementia affects the frontal brain

pick’s disease

what type of dementia is similar to alzheimer's but is more progressive and is linked to parkinson’s

Lewy body

what type of dementia is due to age and chronic HTN

binswangers

what type of dementia is caused by plaques and tangles of tau and amyloid proteins in neurons

alzheimers

what are the essential features of Alzheimers

memory failure, personality changes, difficulty with ADL’s

what are the causes of Alzheimers

genetics (less than 5%), age, females more at risk, African American and hispanic, head injury, environmental (diabetes, high cholesterol, smoking, lack of exercise, obesity, low vitamin D, high stress and depression)

how is Alzheimers diagnosed

no definitive diagnosis except histopathological on post mortem exam. clinical diagnosis made based on patient profile and presenting behaviors and/or cognitive issues

how do you care for those with Alzheimers

no prevention or cure, treat symptoms and support caregivers and family

what are the several methods of staging Alzheimers

functional assessment staging (FAST); addresses 7 major areas of functioning

stages of deterioration; 3 major stages of degeneration (mild, moderate, severe), easier for family to understand

stages of symptom progression; three stages delineated by years up to and after diagnosis

in alzheimers, losses and symptoms vary from person to person, depending on…

extent of brain cell death and loss, location of brain cell death and loss, speed with which losses occur

what are the guidelines for reorientation in Alzheimers patients

only reorient in early stages when confused, validation used in later stages

what are the 12 core primary symptoms of Alzheimers

functional impairment, mood disorders, delusions and hallucinations, dependence in ADLS’s, inability to initiate meaningful activity, anxiety, spatial disorientation, elopement, resistance to care, food refusal, insomnia (don’t use Benadryl) and sundowning, apathy and agitation

what are some behavior interventions for patients with dementia

progressively lowered stress threshold, patients need alternating quiet and stimulating environments, behaviors have meaning, check for physical problems, pain, environment, mind stimulating activities and develop a routine