neuro

Neuro

Jennifer Brewster RN,MSN

Esmeralda Garza RN, MSN

Review A&P

• Neuron, synapse, neurotransmitters

• Composition of CNS

• Cerebral circulation

A&P

• Blood brain barrier

• CSF

• Spinal cord and tracts

• Peripheral nervous system- spinal nerves and sensory receptors

• Reflexes

• Glasgow coma scale

A&P

• Physical assessment-• Normal and abnormal signs• Cranial nerves (type and function)• Motor function• Reflex activity• Posturing

• Diagnostic testing

Headaches

• Headaches have been traced to the 3rd Millennium B.C.

• The physical brain is insensitive to pain• Essential to differentiate primary from secondary

headaches• Most headache sufferers never get a medical

diagnosis because of self-remedies

Headaches

• A physical, fundoscopic and neurological evaluation should be done on all HA patients

• Important for the patient to keep a HA diary- can reveal patterns

• Common triggers- stress, lack of sleep and hunger

Headaches

• Primary• Not associated with

pathology

• Migraine• Cluster• Tension

• Secondary• Have an underlying

pathologic condition

• Infection• Neoplasm• Vascular• Drug induced• Idiopathic

Primary Headaches

• No underlying pathology

• Usually few physical signs

• History helps diagnosis

Secondary headaches

• Different headache

• Worst headache ever

• Comes on quickly

• Neurologic and/or systemic signs ans symptoms

• Changes in headache history

Analgesic rebound headache• AKA- medication overuse headache• Can be from dull to severe headache• Worse in the morning• Analgesics work for a while but chronic

headache remains• More likely with overuse of products with

caffeine or butalbital• TX- completely discontinuing the overused

analgesic• Medication for headache prevention reduces

analgesic use.• Have PCP review medications, if on many at

once, to taper down medications.

Analgesic rebound Headache

• Pt educations is needed to reduce risk of overuse.

• Use of ergots, triptans, opioids, barbiturates- should be limited to no more than 10 days a month.

• Basic analgesics should be limited to no more than 15 days a month.

Cluster headache• Vary rare, 20-40 years old• Most severe pain of the primary

headaches• Typically every 24 hrs for 6-12 wks at a

time• Remission between attacks typically lasts

12 mos.• Have autonomic symptoms• Headache always on the same side• Unilateral headache

Cluster

• Maximum intensity very quickly

• Cannot usually stay still because of the pain.

• May be resistant to therapy

• Alcohol can initiate the attack

• Awakens the person in the middle of the night

• Lasts anywhere from 15 minutes to 4 hrs

Treatment of Cluster HA

• Oxygen therapy- 8-10 L/min at the onset of the headache

• SQ- sumitriptan 6-12 mg (oral not effective)

• Intranasal-Lidocaine 2% 1ml

• Inhaled- Ergotamine 0.5 mg

Prophylactic Cluster TX

• Calcium channel blockers-verapamil 120mg divided into 3-4 doses

• Prednisone- 30-75mg/day then tapered to 5-10 for the duration of the headache

• Lithium- 600-900 mg/day in divided doses• Steroid injections in the occipital nerve

(methlyprednisolone 120mg with lidocaine)• Valproic acid- 250 mg BID (increase to

1gr/day if needed)

Tension Headache

• Most common of the primary headache.• Stress is a common trigger. Others are noise,

emotion or fatigue.• C/O non-specific symptoms• Pain is bilateral, around neck and back of head.

Tightening band pressure.• Does not worsen with exertion.• No neurological deficits. • Females are affected more than males.

Treatment for tension headache

• Non-Pharmacologic-• Stress relief, massage, warm bath, warm pack to

neck or forehead

• Pharmacologic-• Analgesics• Acute- ASA, Acetaminophen, NSAID• Prophylactic (more then 15/mo)- TCA,

Amitriptyline

Migraine

• Family history

• Several triggers

• Stable over time

• Associated with other diseases

• Throbbing/ Pulsatile

Migraine with aura “Classic”

• Visual disturbances –bright lights or loss or area of vision

• Weakness• Sensory symptoms- paresthesias• Signs of brainstem dysfunction-

hemiparesis• Once aura has passed then migraine

continues• Aura typically lasts one hour

Migraine without aura “Common”

• No aura precedes the headache

Triggers

• Teach the patient to avoid known triggers.

• Food and beverages

• Medications

• Other Factors

Key features of migraine headaches

• Phases of Migraine with aura-• First (Prodromal)• Aura develops over a period and lasts no

more than one hour• Well-defined transient focal neurologic

dysfunction exists.• Pain may be preceded by : visual

disturbances, flashing lights, lines or spots, shimmering or zigzag lights

• Pain may be preceded by a variety of neurologic changes, including the following:

• numbness • tingling of the lips or tongue • acute confusional state • aphasia • vertigo• unilateral weakness • drowsiness

Second phase (migraine with aura)

• Headache is accompanied by nausea and vomiting.

• Pain usually begins in the temple; it increases in intensity and becomes throbbing within 1 hour.

Third Phase(Migraine with aura)

• Pain changes from throbbing to dull.

• Headache, nausea, and vomiting last from 4-72 hrs.

Migraine without Aura• Migraine begins without an aura before the

onset of the headache.• Pain is aggravated by performing routine

physical activities.• Pain is unilateral and pulsating.• One of the following is present: • Nausea/vomiting• Photophobia• Phonophobia• Headache lasts for 4-72 hrs.• Migraine usually occurs in the early morning,

during periods of stress, or in those with premenstrual tension or fluid retention.

Table: Adapted IHS Criteria for Migraine with Typical Aura

• A At least 2 attacks fulfilling criteria B

• B Aura consisting of at least one of the following, but no motor weakness: • Fully reversible visual symptoms including positive features (e.g., flickering lights,

spots, or lines) and/or negative features (i.e., loss of vision) • Fully reversible sensory symptoms including positive features (i.e., pins and needles)

and/or negative features (i.e., numbness) • Fully reversible dysphasic speech disturbance

• C At least two of the following: • Homonymous visual symptoms and/or unilateral sensory symptoms • At least one aura symptom develops gradually 5 minutes or more and/or different

aura symptoms occur in succession over 5 or more minutes

• D Headache fulfilling criteria for migraine without aura beginning during the aura or follows the aura within 60 minutes

• WWW.GUIDLINE.GOV

Table: Adapted from IHS Criteria for Migraine without Aura *

• Headache Descriptions (Any 2)• Unilateral • Pulsatile quality • Moderate to severe pain intensity • Aggravation by or causing avoidance of routine physical activity

• Associated Symptoms (Any 1)

• Nausea and/or vomiting • Photophobia and phonophobia

• *Must have 5 attacks fulfilling the above criteria and no signs of a secondary headache disorder. The headaches last 4–72 hours

• WWW.GUIDELINE.GOV

Migraine Treatment

• Non-Pharmacologic-

• Relaxation therapy, behavioral therapy, lifestyle changes, acupuncture

• Herbs

• Pharmacologic- try for at least 6mo and then reassess

• Early intervention is best for preventative and abortive.• Analgesics (ASA, NSAIDs, Excedrin migraine)• Triptans (first line, expensive)• **Triptans not used for prophylaxis and are

contraindicated in ischemic heart disease and uncontrolled HTN.

• Ergotamine and Caffeine• DHE-(nasal,IM,SQ) use if Triptans not effective• Anti-emetics for nausea and vomiting• Abortive therapy is best early and to manage other

symptoms associated with the migraine.

Migraine Prophylaxis

• Anti-epileptic medication-• Topamax, Depakote• Tri-cyclic Antidepressants-• Amitriptyline, Nortriptyline• Anti-hypertensive-• Beta-blockers, calcium channel blockers,

ACE (lisinopril), ARB (candesartan)• Botox

Epilepsy

• Seizure- abnormal, sudden, excessive, uncontrolled electrical discharge of neurons within the brain that may result in alteration of consciousness, motor or sensory ability, and or behavior.

• Epilepsy- chronic disorder characterized by recurrent, unprovoked seizure activity.

• Primary- not associated with brain lesion

• Secondary- results from brain lesion or trauma.

• May also be caused by: metabolic disorder, acute alcohol withdrawal, electrolyte disturbance, heart disease

• Triggers- increased physical activity, emotional stress, excessive fatigue, alcohol or caffeine consumption, certain foods or chemicals

Classification of Seizures

• Generalized seizures

• Partial Seizures

• Unclassified Seizures

Generalized Seizures

• Involve both cerebral hemispheres.

• Absecnce• Generalized Tonic Clonic• Myoclonic• Atonic• Clonic• Tonic

Partial Seizures

• Focal or local seizures, begin in one part of the cerebral hemisphere.

• Often seen in adults• Less responsive to medical treatment.

• Simple Partial

• Complex Partial

Unclassified

• Account for half of all seizure activity

• Occur for no known reason

• Do not fit into other categories

Interventions

• Drug therapy-

• One drug at a time to try to control.

• AED’s

• Ensure drugs given correctly

• Monitor lab values (for pt and drug)

• Watch for drug/drug reaction

Seizure Precautions

Evaluate patient environment-home, work and hospital

In hospital-

IV line

Oxygen

Suction set-up

Airway at bedside (do not insert anything else in mouth)

Padded side rails

Management

• Take appropriate action based on type of seizure

Review medications needed for management

For All Seizures• Time seizure started and ended• LOC• Type of behavior during seizure• Loss of bowel or bladder control• All treatments administered• Vitals• Behavior after seizure• If patient remembers aura• Who was notified• Orders received

Seizure Management

• Acute-

• Greater intensity, number or length than usual

• Treatment-

• Lorazepam (Ativan), diazepam (Valium),

Status Epilepticus*EMERGENCY*

• Prolonged seizures (more than 5 min)• Repeated seizures (over 30 min)

• Causes-• Sudden withdrawal from AED’s• Infection• Acute alcohol withdraw• Head trauma• Cerebral edema• Metabolic disturbance

Treatment

• IV access

• Normal Saline

• ICU management

• Labs, ABG’s

• IV- Diazepam, IV Lorazepam, Phenytoin infusion

• General anesthesia may be needed.

Surgical Management of Seizures

• Vagal Nerve Stimulation

• Conventional surgery

Transient Ischemic Attack

• Lasts for few minutes with all effects gone within 24 hours

• If last longer than 24 hours then consider it a stroke

• May have more than one at a time

• No lasting effects on the brain

• 10-15% chance of stroke within 1 year (highest in next 48 hrs)

S/S of TIA

• Sudden weakness, numbness or paralysis on face, arm or leg, typically one side of the body.

• Slurred or garbled speech or difficulty understanding others.

• Sudden blindness in one or both eyes or double vision

• Dizziness, loss of balance or loss of coordination

Risk factors for TIA

• Non-Modifiable-

• Family history of TIA or Stroke

• Older age

• Men have higher risk

• Blacks have higher risk than other races

Risk Factors for TIA

• Modifiable-• Hypertension control• Heart disease• Smoking• Diabetes• High LDL and Triglycerides• Sedentary Lifestyle• Obesity

Screening/Diagnosis for TIA and Stroke

• Carotid ultrasound

• CT of the head

• CT angiography

• MRI

• MRA

• TEE

• Arteriography

Treatment for TIA

• To help reduce the risk of another TIA or Stroke

• Medications-• Anti-platelets-Plavix and aspirin• Anticoagulant- Heparin and coumadin

• Surgical-• Carotid endarterectomy• Stenting

Stroke

• “Brain attack” is how it is described• Blood flow to the brain is interrupted• Can be ischemic or hemorrhagic• Ischemic can be from thrombus, embolus,

hypoperfusion. Affect local area of brain.• Hemorrhagic can be intercerebral or subarachnoid. Its

effects have systemic symptoms.• Signs and symptoms depend on what part of the brain is

affected.• If symptoms are severe at onset, think subarachnoid

hemorrhage or embolus.

Risk Factors

• Ischemic-• Older patients• HTN• Smoker• Male• A-fib• Cocaine abuse• DM• Sedentary life style

• Hemorrhagic-• 40-60 yrs old• HTN• Family history• SLE• Cocaine use• Pregnancy• Smoker• Intracranial abnormalities

Stroke Stats www.strokeassociation.org

• Impact of stroke-• About 700,000 Americans each year suffer a new or

recurrent stroke. That means, on average, a stroke occurs every 45 seconds.

• Stoke kills more than 150,000 people a year. That is about 1 of every 16 deaths.

• On average, every 3 to 4 minutes someone dies of a stroke.

• Of every 5 deaths from stroke, 2 occur in men and 3 in women.

• Americans will pay about $62.7billion in 2007 for stroke related medical costs and disability.

Left vs Right

• Language- aphasia• Memory- possible deficit• Vision- Reading

problems, inability to discriminate words and letters

• Behavior- slow, quick anger, intellectual impairment, anxiety with new tasks

• Hearing- no deficit

• Language- Impaired sense of humor

• Memory- disoriented to time, person, place

• Vision- loss of depth perception

• Behavior- poor judgment, impulsive, lack of awareness of neurologic deficit

• Hearing- loss of ability to hear tonal variations

Ischemic

• Cause 80% of strokes

• Headache not common

• Intermittent progression

• Do not lower blood pressure too quickly- labetolol can be used

• Can be from thrombus, embolus or systemic hypoperfusion

Emergency

• If stroke suspected- must go to ED right away (with CT capability and tPA)

• tPA for ischemic stroke (thrombolytic therapy)

• Have 3 hour window for treatment

Subarachnoid Hemorrhage

• 40% mortality

• Sudden and severe onset

• Vomiting and coma develop later as well as nuchal rigidity

• Causes are rupture of cerebral aneurysm or trauma

• CT scan of brain to find bleeding or lumbar puncture to look for blood in CSF

S. H.

• TX- surgical clipping of aneurysm and blood pressure control. Surgical intervention for evacuation of blood or control of bleeding.

• Phenytoin to prevent seizures• Laxatives, stool softeners• Nimodipine 60 mg q4 to reduce vasospasm• Neurological checks important to watch for early

deterioration of condition• Headache should be treated but opiates are not

recommended because they can mask neurological changes.

Complications of stroke

• On every organ system initially• Later complications depend on the extent

and location of the stroke

• Some complications-• Pneumonia, decubitis, depression,

contractures, DVT, constipation, aphasia, dysphagia, inability to walk, memory loss, motor coordination problems, death

Rehabilitation

• Essential to identify modifiable risk factors and work aggressively at treating them.

• Rehabilitation in many forms is available- rehabilitation hospital, outpatient therapy, support groups

• SNF or Long term care may be needed if the patient or family cannot care for them

• Important to discuss pt’s wishes regarding care- DNR, living will, power of attorney

Alzheimer’s Disease

• Dementia Alzheimer’s Type (DAT)

• Chronic, progressive, degenerative disease

• Over time- increasingly cognitively impaired, physical deterioration, death as a result of complications.

• Anyone over 40 yrs/old

• No proven way to prevent AD

Assessment

• Ask patient about changes• Ask family as well- pt may cover up changes• No lab test to confirm diagnosis• DX done at autopsy of brain

• Changes in cognition• Changes in behavior and personality• Changes in self-care skills

Assessments

• Laboratory tests

• CT and PET Scans

• MRI

• Neurological evaluation

Factors That Can Worsen Disease

• Stroke• Subdural hematoma• MI• Hypoglycemia• Infection• Pain • Drugs• Physical restraint

Stages

• Early- Stage I

• Forgets names, misplaces items

• Mild memory loss

• Unable to travel alone to new destination

• Wanders

• Decreased sense of smell

• Middle- Stage II

• Gross intellectual impairments

• Incontinent

• Wanders

• Loss of ability to care for self

• Complete disorientation to time, place, event

• Physical impairments

• Late (severe) Stage III-

• Completely incapacitated

• Total dependence for ADL’s

• Loss of motor and verbal skills

• Neurologic deficits

Interventions

• Structure the environment

• Re-orient the patient frequently

• Promote independence with ADL’s

• Ensure safety

• Provide caregiver with outside resource information

Drug therapy

• Cholinesterase inhibitors-• For symptomatic treatment of AD• Do not affect course of disease• Delay onset of cognitive decline• ARicept, Reminyl, Exelon, Namenda• Anti-depressants – Paxil, Zoloft• Anti-psychotic drugs• Complimentary therapy to slow progression

and/or minimize other symptoms

Nursing Diagnosis

• Chronic Confusion related to AD

• Risk for injury r/t problems with orientation

• Compromised family coping and caregiver role strain r/t the client’s prolonged progression of disability and client’s increasing care needs