Neuro

Phenytoin (Dilantin) is an anticonvulsant drug used to treat generalized tonic-clonic seizures.

  • the range is between 10-20 mcg/mL

  • Early signs of toxicity include horizontal nystagmus and gait unsteadiness

  • followed by dysarthria “slurred speech”, lethargy, confusion, ataxia (balance and coordination), and even coma (neuro symptoms)

  • phenytoin can cause gingival hyperplasia (overgrowth of the gum tissues or reddened gums that bleed easily), especially in high doses.  Folic acid supplementation can also reduce this side effect.

  • a diet high in folic acid and calcium should be recommended. Foods such as milk, cantaloupe and kale.

  • Don't stop abruptly-can increase seizure

  • Use non-hormonal BC

  • antacids, calcium supplements) and/or nutritional enteral tube feedings can decrease the absorption and the serum level of this drug.

priority action is to stop the feeding for 1 to 2 hours before and after administering phenytoin

Bacterial meningitis

Clinical manifestations of bacterial meningitis in infants age <2 include:

  • Fever or possible hypothermia
  • Irritability, frequent seizures
  • High-pitched cry
  • Poor feeding and vomiting
  • Nuchal rigidity
  • Bulging fontanelle is possible but not always present
  • Priority of care is administrating antibiotics
  • +Sign of brunski and kernigs

The nurse's first action is to put on Droplet precautions

The nurse should administer IV fluids FIRST then antibiotics due to hypotension. Then antibiotics after 24 hrs of the antibiotics dc the precautions.

One of the most common acute complications of bacterial meningitis in children is hydrocephalus long term causes learning disability, hearing loss, and brain damage

*Side Note: The Babinski reflex can be present for up to 1-2 years

Midazolam (Versed) is a benzodiazepine

Side effects can include airway occlusion, apnea, hypotension (especially in the presence of an opioid), and oxygen desaturation with resultant respiratory arrest.

Flumazenil (Romazicon) is the antidote drug used to reverse the sedative effects of benzodiazepines.

Hydrocephalus

bulging fontanelles, increasing head circumference, and sunset eyes (or setting-sun sign) (sclera visible above the iris).

This is a late sign of increased ICP that requires timely treatment (eg, shunt placement) and is the priority

Bell's palsy is an inflammation of cranial nerve VII (facial) that causes motor and sensory alterations.

client teaching should include the following:

  1. Eye care: Use glasses during the day; wear a patch (or tape the eyelids) at night to protect the exposed eye.  Use artificial tears during the day as needed to prevent excess drying of the cornea. Wear a patch on the Right eye
  2. Oral care: Chew on the unaffected side if right-sided bells palsy chews on the left side to prevent food trapping; a soft diet is recommended.  Maintain good oral hygiene after every meal to prevent problems from accumulated residual food (eg, parotitis, dental caries)

Manifestations of Bell palsy include:

  • Inability to completely close the eye on the affected side
  • Alteration in tear production (eg, decreased tearing with extreme dryness, excessive tearing) due to weakness of the lower eyelid muscle (change in lacrimation)
  • Flattening of the nasolabial fold on the side of the paralysis
  • Inability to smile or frown symmetrically

Alteration in the sensory fibers can cause loss of taste on the anterior two-thirds of the tongue.

succinylcholine (Anectine) is used to induce general anesthesia.

In MH-susceptible clients, the triggering agent leads to excessive release of calcium from the muscles, leading to sustained muscle contraction and rigidity (usually of the jaw and upper body [early sign]), increased oxygen demand and metabolism, and dangerously high temperature (later sign).

Most critical (priority) As MH is an inherited condition, proper screening and a thorough preoperative nursing assessment and health history can help minimize the client's risk

INterventions-

Head tilt and chin lift is a maneuver used to open the airway.  The tongue may fall back and occlude the airway due to muscular flaccidity after general anesthesia.  Manifestations associated with airway obstruction include snoring, use of accessory muscles, decreased oxygen saturations, and cyanosis.

The nurse would notify the health care provider, indicating the need for immediate treatment (eg, dantrolene, cooling blanket, fluid resuscitation)

 The most specific characteristic signs and symptoms of MH include hypercapnia (earliest sign) CO2>45, generalized muscle rigidity (eg, jaw, trunk, extremities), and hyperthermia.

Using a rigid cervical collar, cervical spine immobilization must be maintained throughout the client assessment to minimize further injury

sudden deceleration (eg, fall, motor vehicle collision) causes bodily injury.  If the client is not wearing a seatbelt during an automobile crash, the client may strike (or be propelled through) the windshield, causing blunt-force trauma to the head, neck, or spine.

use the jaw-thrust technique

carotid endarterectomy is a surgical procedure performed to remove plaque

(priority) nurse must closely assess for signs of new or worsening alterations in neurologic status, as surgical manipulation of arteries and blood flow increases the risk of stroke.

Nurses should use the FAST acronym to assess for stroke

  • Facial drooping:  Numbness or droopiness on one side of the face
  • Arm weakness:  Weakness or drifting of one arm when raised to shoulder level
  • Speech difficulties:  Slurring of words, incomprehensible speech, inability to understand others
  • Time:  Notation of the time of symptom onset, which is critical for guiding treatment

Parkinson's disease (movement disease) -is usually characterized as (bradykinesia) decreased movement, increased muscle tone “rigidity”, tremors, and shuffling gate.

Because of these alterations, accommodations are often needed when nurses provide client teaching, including:

  • Teaching and encouraging the client to speak slowly, enunciate words, and pause to take deep breaths because speech disturbances are common in PD and may lead to frustration if misunderstandings occur
  • Identifying and promoting the client's strengths during teaching because cognitive and physical alterations in PD can negatively affect body image and lead to depression
  • Carbidopa-levodopa (Sinemet) once started should never be stopped suddenly as this can lead to an akinetic crisis (complete loss of movement).
  • Identifying times of day when the client functions optimally and scheduling teaching/activities during the late morning
  • Ensuring that teaching occurs at times without rushing or interruptions because several factors in clients with PD (eg, fatigue, depression, cognitive impairment) may impair the ability to process teaching quickly
  • Symptoms- stooped posture, shuffling gate, reduced arms swing, masked face, flexed elbow, trembling of extremities

Client teaching for carbidopa-levodopa includes:

  • Implementing fall precautions (eg, changing positions slowly, removing rugs), as orthostatic hypotension is a common side effect
  • Knowing that carbidopa-levodopa takes several weeks to reach its maximum effectiveness
  • Understanding that harmless discoloration (eg, red, brown, black) of secretions (eg, urine, perspiration, saliva) may occur while taking carbidopa-levodopa
  • Avoiding high-protein meals, which interfere with the absorption of carbidopa-levodopa

tricyclic antidepressants (eg, amitriptyline, nortriptyline, desipramine, imipramine) are commonly used for neuropathic pain.  Side effects are especially common in elderly clients.

Anticholinergic effect;

Dry mouth constipation, urinary retention, blurred vision. Avoid glaucoma and BPH

Myelomeningocel-spina bifida

cover the area with a sterile, moist dressing to decrease the risk of infection until surgical repair can occur.

at risk for hydrocephalus from the excess cerebrospinal fluid.  An occipital frontal circumference is needed as a baseline measurement but is not a priority.

the newborn would be placed in the prone position “tummy” (with face turned to the side) to prevent rupture

Receptive aphasia impaired understanding of speech and writing

  • Ask short, simple, "yes" or "no" questions
  • Use gestures or pictures (eg, communication board) to demonstrate activities
  • Remain patient and calm, allowing the client time to understand each instruction

Dysarthria is the weakness of the muscles used for speech Comprehension and the meaning of words is intact, but speech is difficult to understand (eg, mumble, lisp).

Dysphagia refers to difficulty swallowing.

Apraxia refers to the loss of the ability to perform a learned movement (eg, whistling, clapping, dressing)

Broca (expressive) aphasia-damage to the frontal lobe.

can comprehend speech but demonstrate speech difficulties.

Broca aphasia are aware of their deficits and can become frustrated easily

Clients with damage to the temporal portion of the brain may develop Wernicke (fluent) aphasia (ie, the inability to comprehend the spoken and/or written word) and exhibit a long, but meaningless, speech pattern. Use yes or no questions and use picture boards

Amyotrophic lateral sclerosis (ALS), also known as Lou Gehrig disease, is a debilitating, progressive neurodegenerative disease with no cure.

Clients develop fatigue and muscle weakness that progresses to paralysis, dysphagia, difficulty speaking, and respiratory failure.  Most clients diagnosed with ALS survive only 3-5 years.

Riluzole (Rilutek) is the only medication approved for ALS treatment.

riluzole may slow disease progression and prolong survival by 3-6 months. Provide teaching.

Treatment focuses on symptom management.  Interventions include:

  • Respiratory support with noninvasive positive pressure (eg, bilevel positive airway pressure [BiPAP]) or invasive mechanical ventilation (eg, via tracheostomy)
  • A feeding tube for enteral nutrition
  • Medications to decrease symptoms (eg, spasms, uncontrolled secretions, dyspnea)
  • Mobility assistive devices (eg, walker, wheelchair)
  • Communication assistive devices (eg, alphabet boards, specialized computers)

multiple sclerosis (MS) is a progressive, demyelinating disease of the central nervous system that interrupts nerve impulses, causing a variety of symptoms.  Symptoms may vary, but muscle weakness, spasticity, incoordination, loss of balance, and fatigue are usually present, causing impaired mobility and risk for fall and injury, walking with the feet apart.

Clients should also exercise when the weather is cool and stay hydrated; dehydration and extremes in temperature cause symptom exacerbation.

Trigeminal neuralgia (cranial nerve V)

  • The primary intervention for trigeminal neuralgia is consistent pain control
  • The drug of choice is carbamazepine.
  • highly effective for neuropathic pain
  • Carbamazepine is associated with agranulocytosis (leukopenia) and infection risk. “Low WBC”

Behavioral interventions include the following:

  1. Oral care – use a small, soft-bristled toothbrush or a warm mouth wash
  2. Use lukewarm water; avoid beverages or food that are too hot or cold
  3. Room should be kept at an even and moderate temperature
  4. Avoid rubbing or facial massage.  Use cotton pads to wash the face if necessary.
  5. Have a soft diet with high-calorie content; avoid foods that are difficult to chew.  Chew on the unaffected side of the mouth.

Clients with a high (T6 or above) spinal cord injury are at risk for autonomic dysreflexia (autonomic hyperreflexia).

Classic signs include hypertension (up to 300 mm Hg systolic), throbbing headache,

diaphoresis above the level of injury, bradycardia (30-40/min), piloerection ("goose bumps"),

flushing, and nausea.  This is a life-threatening condition that requires immediate intervention to prevent complications (eg, hypertensive stroke, seizures).

Clients with a spinal cord injury should have their blood pressure checked when they report a headache

The most common cause of autonomic dysreflexia is bladder irritation due to distention.  The client needs to be catheterized or the possibility of a kink in the existing catheter must be assessed

Bowel impaction can also be a cause; a digital rectal examination should be performed.

Constrictive clothing should be removed  

the head of the bed is elevated 45 degrees or high Fowler's to lower blood pressure.

nifedipine may be prescribed.

Thrombolytic agents (eg, alteplase, tenecteplase, reteplase) are often prescribed to resolve acute thrombotic events (eg, ischemic stroke, myocardial infarction, massive pulmonary embolism). contraindicated in clients with active bleeding, recent trauma, aneurysm, arteriovenous malformation, history of hemorrhagic stroke, and uncontrolled hypertension (blood pressure >180/110 mm Hg).

status epilepticus, a serious and life-threatening emergency in which a client has been seizing for 5 minutes or longer.  Grunting and a dazed appearance are 2 common signs.  A client with hydrocephalus (abnormal collection of cerebrospinal fluid in the head) and a ventriculoperitoneal (VP) shunt is at a higher risk for seizures.  Stopping seizure activity is the first nursing priority IV benzodiazepines (diazepam or lorazepam) are used acutely to control seizures.  However, rectal diazepam is often prescribed when the IV form is unavailable or problematic

parents often get prescriptions for rectal diazepam and are advised to administer a dose before bringing a child to the emergency department.

Blood pressure for a 1yrs old is 100-160bpm

Electroencephalogram (EEG) is a diagnostic procedure used to evaluate the presence of abnormal electrical discharges in the brain.

Teaching for the parent includes the following:

  1. Hair should be washed to remove oils and hair care products, and accessories such as ribbons or barrettes should be removed.  Hair may need to be washed after the procedure to remove electrode gel.
  2. Avoid caffeine, stimulants, and central nervous system depressants prior to the test.
  3. The test is not painful, and no analgesia is required.

When transferring a client from bed to chair the following are recommended for client safety:

  1. Clients should wear nonskid shoes (first step)
  2. Make sure the bed and chair (wheelchair) brakes are locked
  3. Use a transfer belt.  A transfer belt worn around the client's waist allows the nurse to assist the client while maintaining proper body mechanics and safety.
  4. Transfer the client toward the stronger (not the weaker) side.  If the client is weak on the left side, ask the client to pivot on the right side

St. John's wort is an herbal product commonly used by many clients to treat depression.

Taking St. John's wort with (SSRIs/SNRIs), and monoamine oxidase inhibitors (MAOIs) can lead to a dangerous condition called serotonin syndrome.

 

Signs: Excessive serotonin causes symptoms ranging from mild (shivering and diarrhea) to severe (muscle rigidity, fever, and seizures). Tremors, hypertension, dilated pupils (Mydriasis), sweating.

Aspiration-pneumonia prevention measures include:

  • Thicken liquids (eg, to nectar or honey consistency) for clients with dysphagia; thin liquids are more difficult to control when swallowing
  • Ensure that the client is fully awake before eating.  The nurse should time the administration of sedating medications (eg, opioids, benzodiazepines) to avoid sedation during meals
  • Elevate the head of the bed to 90 degrees during and for 30 minutes after meals, and never place the head of the bed lower than 30 degrees
  • Encourage clients to facilitate swallowing by flexing the neck (chin to chest)
  • Administer prescribed antiemetics (eg, ondansetron) as needed to prevent vomiting.
  • Monitor for coughing, gagging, and pocketing food.

Scopolamine is an anticholinergic medication used to prevent nausea and vomiting from motion sickness. Place on a hairless and dry area in the back of the ear :)

Clients should be instructed to:

  • Apply the patch ≥4 hours before starting travel to allow for absorption and medication onset.  Transdermal patches have a slower onset but a longer duration of action.
  • Replace the patch every 72 hours as prescribed to ensure continuous medication delivery.
  • Remove and discard the old patch before placing a new one to prevent accidental overdose
  • Dispose of the old patch out of reach of children and pets to avoid accidental ingestion
  • Wash hands with soap and water after handling the patch to avoid inadvertent drug absorption or contact with the eyes

Prior to a lumbar puncture, clients are instructed as follows:

  1. Empty the bladder before the procedure
  2. The procedure can be performed in the lateral recumbent position or sitting upright.  These positions help widen the space between the vertebrae and allow easier insertion of the needle
  3. A sterile needle will be inserted between the L3/4 or L4/5 interspace
  4. Pain may be felt radiating down the leg, but it should be temporary

After the procedure, instruct the client as follows:

  1. Lie flat with no pillow for at least 4 hours to reduce the chance of a  spinal fluid leak and resultant headache
  2. Increase fluid intake for at least 24 hours to prevent dehydration

Botulism

Manifestations include descending flaccid paralysis (starting from the face), dysphagia, and constipation (smooth muscle paralysis).

The main source is improperly canned or stored food.  A metal can's swollen/bulging end can be caused by the gasses from C botulinum and should be discarded.  The infant form of botulism can occur in children under the age of 1 year if they eat honey, particularly raw (wild) honey.

Management of infant botulism often includes administering intravenous botulism immune globulin (BIG-IV),

In addition, close monitoring and supportive care (eg, mechanical ventilation, enteral tube feedings) are provided.

cranial nerve (CN) VIII, the vestibulocochlear (or auditory) nerve.

Symptoms of impairment may include loss of hearing, dizziness,vertigo, and motion sickness, which place the client at a high risk for falls

Transsphenoidal hypophysectomy is the surgical removal of the pituitary gland risk for developing neurogenic diabetes insipidus

Clinical manifestations associated with DI include:

  • Decreased urine specific gravity (
  • Elevated serum osmolality (>295 mOsm/kg [295 mmol/kg
  • Hypernatremia (>145 mEq/L [145 mmol/L]
  • Hypovolemia and potential hypotension
  • Polydipsia
  • Polyuria (2-20 L/day)

Preventing activities that increase ICP or blood pressure will minimize further bleeding.  The nurse should:

  • Reduce stimulation, maintain a quiet and dimly lit environment, limit visitors

  • Administer stool softeners to reduce strain during bowel movements (Option 1)

  • Reduce exertion, maintain strict bed rest, assist with activities of daily living

  • Maintain head in a midline position to improve jugular venous return to the heart

  • Elevating the head of the bed to 30 degrees with the head/neck in a neutral position to reduce venous congestion

  • Administering stool softeners to reduce the risk of straining (eg, Valsalva maneuver)

  • Managing pain well while monito

  • Managing fever (eg, cool sponges, ice, antipyretics) while preventing shivering

  • Maintaining a calm environment with minimal noise (eg, alarms, television, hall noise) f

  • Ensuring adequate oxygenation

  • Hyperventilating and preoxygenating the client before suctioning; reducing CO2 (a potent cerebral vasodilator) by hyperventilation induces vasoconstriction and reduces ICP

During interventions, ICP should not exceed 25 mm Hg

  Enoxaparin is an anticoagulant used to prevent venous thromboembolism (VTE).  Anticoagulants are contraindicated in clients with hemorrhagic stroke; the nurse should question any prescriptions that increase the risk of bleeding.  A client with hemorrhagic stroke should instead receive nonpharmacologic interventions (eg, compression stockings) to prevent VTE.

Myasthenia gravis is an autoimmune disease.(think of Lazy John)-Hallmark signs weakness with activity

As a result, there is fluctuating weakness of skeletal muscles, most often presented as ptosis/diplopia (Cranial nerve III), bulbar signs (difficulty speaking or swallowing), and difficulty breathing.  Muscles are stronger in the morning and become weaker with the day's activity as the supply of available acetylcholine is depleted.

anticholinesterase drugs (pyridostigmine [Mestinon]) that are administered before meals so that the client's ability to swallow is strongest during the meal

Semi-solid foods (easily-chewed foods) are preferred over solid foods (to avoid stressing muscles involved in chewing and swallowing) or liquids (aspiration risk)

Receive annual flu and pneumococcal vaccine for prevention of infection

PH 7.32-7.45

PaO2 80-100

PaCO2 35-45

HCO3 22-26

O2 95-99

ARF are PaO2 ≤60 mm Hg (8.0 kPa) or PaCO2 ≥50 mm Hg (6.67 kPa).

positive-pressure mechanical ventilation may be necessary.

All clients with a serious chronic co-morbidity should receive the annual flu vaccine (also the pneumonia vaccine if appropriate) as they are more likely to have a negative outcome if the illness is contracted.  It is especially important in clients with myasthenia gravis as the flu (or pneumonia) would tax the already compromised respiratory muscles

Infection, under medication, and stress can precipitate a life-threatening myasthenic crisis, which is characterized by oropharyngeal and respiratory muscle weakness and respiratory failure.  This client's infection and increasing difficulty swallowing indicate the need for immediate intervention

Cushing's triad is related to increased intracranial pressure (ICP).        

Later signs include bradycardia, increased systolic blood pressure with a widening pulse pressure (difference between systolic and diastolic), and slowed irregular (Cheyne-Stokes) respirations.

Mannitol (Osmitrol) is an osmotic diuretic used to treat cerebral edema

if a higher dose of mannitol is given or it accumulates (as in kidney disease), fluid overload that may cause life-threatening pulmonary edema results.  An early sensitive indicator of fluid overload is the new onset of crackles auscultated in the lungs.

a priority "most important" To prevent these complications, clients require frequent monitoring of serum osmolarity, input and output, serum electrolytes, and kidney function.

The occipital lobe of the brain registers visual images.  Injury to the occipital lobe could result in a deficit in vision.  The nurse should notify the health care provider immediately and document the finding.

The lobe controls higher-order processing, such as executive function and personality.  Injury to the frontal lobe often results in behavioral changes.

The temporal lobe integrates visual and auditory input and past experiences.

The parietal lobe integrates somatic and sensory input

Parkinsons

(eg, benztropine, trihexyphenidyl) are commonly used to treat tremors in these clients.  However, caution must be taken in clients with benign prostatic hyperplasia or glaucoma as anticholinergic drugs can precipitate urinary retention and an acute glaucoma episode.  As a result, such medications are contraindicated in these clients.

Guillain Barre Syndrome (GBS) is an acute, immune-mediated polyneuropathy that is most often accompanied by ascending muscle weakness and absent deep tendon reflexes. Goes from the Legs and upwards

Early signs indicating impending respiratory failure include:

  • Inability to cough
  • Shallow respirations
  • Dyspnea and hypoxia <02 95
  • Inability to lift the head or eye brows

Many clients have a history of the antecedent respiratory tract or GI infection.  Lower-extremity weakness progresses over hours to days to involve the thorax, arms, and cranial nerves.  However, neuromuscular respiratory failure is the most life-threatening complication.

Assessing the client's pulmonary function by serial spirometry is also recommended.  Measurement of forced vital capacity (FVC) is the gold standard for assessing ventilation; a decline in FVC indicates impending respiratory arrest requiring endotracheal intubation.

Febrile seizures are an alarming experience for parents.  They most commonly occur in children between ages 6 months to 6 years, with the peak of incidence occurring at age 18 months.  The etiology is unknown.

safety precautions (eg, side-lying positioning, removal from harmful environments).  Parents should use antipyretics such as acetaminophen or ibuprofen (in children age >6 months) to control fever and make the child more comfortable

additional cooling methods that may be beneficial for reducing fever include applying

cool, damp compress to the forehead; increasing air circulation in the room; and wearing loose or minimal clothing.

Parents should be instructed to call 911 and seek medical assistance for a seizure lasting more than 5 minutes

A concussion is considered a minor traumatic brain injury and results from blunt force or an acceleration/deceleration head injury.  Typical signs of concussion include:

  1. A brief disruption in level of consciousness
  2. Amnesia regarding the event (retrograde amnesia)
  3. Headache

Family members should observe these clients closely and not participate in strenuous or athletic activities for 1–2 days.  Rest and a light diet are encouraged during this time.

Huntington's disease (HD) is an incurable autosomal dominant hereditary disease that causes progressive nerve degeneration

Chorea (involuntary, tic-like movement) is a hallmark sign.  

respiratory complications typically occur within 20 years of diagnosis.

Autosomal dominant traits require only one copy of the affected gene (from one carrier parent) to manifest (eg, cause disease).

Clients who have a parent with HD and are considering having biological children should receive genetic counseling

The Coup the area "frontal lobe"- speech (Broca area), and voluntary movement are controlled by the frontal lobe.

The contrecoup most likely injured the "occipital lobe", where vision is processed.

Tissue plasminogen activator (tPA) dissolves clots and restores perfusion in clients with ischemic stroke.

It must be administered within a 3- to 4½-hour window

Surgery within the last 2 weeks is a contraindication

stroke or head trauma in the last 3 months could exclude tPA use.

Positional plagiocephaly (flat head syndrome) occurs when an infant is placed in the same position (eg, supine) for an extended period of time and the pliable skull molds to the surface (flattens)

Parents can intervene to avoid or correct plagiocephaly (eg, periodically repositioning the head during sleep, tummy time).