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  • 1. Neuro Jennifer Brewster RN,MSN Esmeralda Garza RN, MSN
  • 2. Review A&P • Neuron, synapse, neurotransmitters • Composition of CNS • Cerebral circulation
  • 3. A&P • Blood brain barrier • CSF • Spinal cord and tracts • Peripheral nervous system- spinal nerves and sensory receptors • Reflexes • Glasgow coma scale
  • 4. A&P • Physical assessment- • Normal and abnormal signs • Cranial nerves (type and function) • Motor function • Reflex activity • Posturing • Diagnostic testing
  • 5. 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
  • 6. 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
  • 7. Headaches • Primary • Not associated with pathology • Migraine • Cluster • Tension • Secondary • Have an underlying pathologic condition • Infection • Neoplasm • Vascular • Drug induced • Idiopathic
  • 8. Primary Headaches • No underlying pathology • Usually few physical signs • History helps diagnosis
  • 9. Secondary headaches • Different headache • Worst headache ever • Comes on quickly • Neurologic and/or systemic signs ans symptoms • Changes in headache history
  • 10. 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.
  • 11. 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.
  • 12. 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
  • 13. 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
  • 14. 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
  • 15. 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)
  • 16. 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.
  • 17. 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
  • 18. Migraine • Family history • Several triggers • Stable over time • Associated with other diseases • Throbbing/ Pulsatile
  • 19. 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
  • 20. Migraine without aura “Common” • No aura precedes the headache
  • 21. Triggers • Teach the patient to avoid known triggers. • Food and beverages • Medications • Other Factors
  • 22. 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
  • 23. • 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
  • 24. 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.
  • 25. Third Phase (Migraine with aura) • Pain changes from throbbing to dull. • Headache, nausea, and vomiting last from 4-72 hrs.
  • 26. 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.
  • 27. 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
  • 28. 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
  • 29. Migraine Treatment • Non-Pharmacologic- • Relaxation therapy, behavioral therapy, lifestyle changes, acupuncture • Herbs
  • 30. • 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.
  • 31. Migraine Prophylaxis • Anti-epileptic medication- • Topamax, Depakote • Tri-cyclic Antidepressants- • Amitriptyline, Nortriptyline • Anti-hypertensive- • Beta-blockers, calcium channel blockers, ACE (lisinopril), ARB (candesartan) • Botox
  • 32. 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.
  • 33. • 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
  • 34. Classification of Seizures • Generalized seizures • Partial Seizures • Unclassified Seizures
  • 35. Generalized Seizures • Involve both cerebral hemispheres. • Absecnce • Generalized Tonic Clonic • Myoclonic • Atonic • Clonic • Tonic
  • 36. 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
  • 37. Unclassified • Account for half of all seizure activity • Occur for no known reason • Do not fit into other categories
  • 38. 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
  • 39. 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
  • 40. Management • Take appropriate action based on type of seizure Review medications needed for management
  • 41. 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
  • 42. Seizure Management • Acute- • Greater intensity, number or length than usual • Treatment- • Lorazepam (Ativan), diazepam (Valium),
  • 43. 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
  • 44. Treatment • IV access • Normal Saline • ICU management • Labs, ABG’s • IV- Diazepam, IV Lorazepam, Phenytoin infusion • General anesthesia may be needed.
  • 45. Surgical Management of Seizures • Vagal Nerve Stimulation • Conventional surgery
  • 46. 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)
  • 47. 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
  • 48. 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
  • 49. Risk Factors for TIA • Modifiable- • Hypertension control • Heart disease • Smoking • Diabetes • High LDL and Triglycerides • Sedentary Lifestyle • Obesity
  • 50. Screening/Diagnosis for TIA and Stroke • Carotid ultrasound • CT of the head • CT angiography • MRI • MRA • TEE • Arteriography
  • 51. 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
  • 52. 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.
  • 53. 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
  • 54. 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.
  • 55. 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
  • 56. 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
  • 57. 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
  • 58. 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
  • 59. 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.
  • 60. 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
  • 61. 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
  • 62. 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
  • 63. 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
  • 64. Assessments • Laboratory tests • CT and PET Scans • MRI • Neurological evaluation
  • 65. Factors That Can Worsen Disease • Stroke • Subdural hematoma • MI • Hypoglycemia • Infection • Pain • Drugs • Physical restraint
  • 66. Stages • Early- Stage I • Forgets names, misplaces items • Mild memory loss • Unable to travel alone to new destination • Wanders • Decreased sense of smell
  • 67. • Middle- Stage II • Gross intellectual impairments • Incontinent • Wanders • Loss of ability to care for self • Complete disorientation to time, place, event • Physical impairments
  • 68. • Late (severe) Stage III- • Completely incapacitated • Total dependence for ADL’s • Loss of motor and verbal skills • Neurologic deficits
  • 69. Interventions • Structure the environment • Re-orient the patient frequently • Promote independence with ADL’s • Ensure safety • Provide caregiver with outside resource information
  • 70. 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
  • 71. 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

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