Unit 4 study guide part 2 Meningitis Def: inflammation of meninges, which are the membranes that protect the

brain and spinal cord viral (aseptic) is most common, bacterial (septic) is contagious with high mortality risk factors: viral illness such as mumps, measles, herpes, arboviruses, or bacterial illness such as pneumonia, if certain microbs are present symptoms: excruciating, constant headache, stiff neck, photophobia objective data: fever/chills, nausea/vomiting, altered level of consciousness, pain with leg extension, flexion of extremities with deliberate flexion of patients neck, hyperactive deep tendon reflexes, tachycardia, seizures, red macular rash, restlessness, irritability Lab test: 1. urine, throat, nose, blood culture and sensitivity: not definitive for meningitis but can guide initial selection of antimicrobial 2. CBC: will show elevated WBC Diagnostic procedures: 1. CSF analysis: most accurate diagnostic procedure, collected during a lumbar puncture. Results indicative of meningitis include: cloudy appearance, elevated WBC, elevated protein, decreased glucose, elevated CSF pressure 2. CT scan or MRI: may show increased intracranial pressure and/or abscess Nursing care: 1. isolate patient, maintain droplet precautions 2. fever reduction measures 3. decrease environmental stimuli 4. best rest, head elevated 30 degrees 5. replace fluid and electrolytes as indicated 6. older adults at increased risk for secondary complications such as pneumonia Medications: 1. Ceftriaxone (Recephin) or cefotaxim (Claforan): antibiotics 2. Phenytoin (Dilantin): anticonvulsants given if ICP increases or client experiences a seizure 3. acetaminophen (Tylenol), ibuprofen (motrin): analgesics for head or fever 4. ciprofloxacin: prophylactics for people who are in close contact with patient Complications: 1. increased ICP 2. syndrome of inappropriate anti diuretic hormone 3. septic emboli (leads to disseminated intravascular coagulation)

Brain Abscess Def: collection of infectious material within brain, bacteria is most common causative organism Symptoms: 1. alterations in intracranial dynamics (edema, brain shift) 2. headache, usually worse in the morning 3. fever, vomiting and focal defects Diagnostic Studies 1. MRI and CT can identify size and location 2. blood cultures, if abscess is believed to arise from bacterial source 3. Chest xray, to rule out predisposing lung infections

Medications: 1. antibiotics, large IV doses to penetrate blood- brain barrier to reach abscess 2. corticosteroids, reduce inflammatory cerebral edema 3. antiseizure: phenytoin, phenobarbital. Nursing care: 1. aimed at controlling ICP, draining abscess 2. assess neurologic status, due to changes in ICP

Encephalitis def: acute inflammatory process of the brain tissue Three types: 1. Herpes simplex: most common in United States 2. Arthropod borne: (such as mosquito transmission), West Nile and St. Louis are the most common types 3. Fugal: occur rarely in healthy people Symptoms: 1. fever, headache, confusion 2. focal neurologic symptoms reflect the specific areas of inflammation 3. dysphasia, hemiparesis, altered LOC Diagnostic test: neuroimaging studies such as MRI, EEG, and CSF used to diagnose and differentiate between the three types Medications: typically treatment for all three are aimed at controlling seizures by standard antiseizure meds and controlling a possible increase in ICP by lumbar puncture 1. acyclovir: antiviral agent, med of choice for herpes encephalitis 2. No specific med is used for arboviarl, treatment is aimed at controlling seizures and increased ICP 3. management for fungal is controlled by antifungal agents Nursing care: 1. assessment of neurologic function 2. monitor blood chemistry and urinary output from acyclovir therapy

Multiple Sclerosis Def: chronic and pregressive disease with no known cure, symptoms become more severe over time due to development of plaque in the white matter of the CNS which damages the myelin sheath Risk factors: 1. onset typically between 20 and 40 years 2. occurs twice as often in women 3. etiology is unknown Factors that trigger relapse: virsuses and infectious agents, living in cold climate, physical injury, stress, pregnancy, fatigue, overexertion, temperature extremes Symptoms: 1. fatigue 2. pain or paresthesia 3. Dipolpia (changes in peripheral vision) 4. Uhthoffs sign (temporary worsening of vision) 5. Tinnitus, vertigo, decreased hearing acuity 6. Dysphagia 7. Dysarthria

8. Muscle spasticity 9. Ataxia 10. Bowel/bladder dysfunction lab test: cerebrospinal fluid analysis show elevated protein level and increase in WBCs diagnostic procedures: MRI reveals plaque Nursing care: need to monitor visual acuity, speech patterns, swallowing, activity tolerance, skin integrity, encourage fluid intake to decrease risk of UTI, monitor cognitive changes, facilitate communication, exercise and stretch muscles, promote safety Medications: 1. Azathiprine (Imuran) and cyclosporine (Sadiummune), both are immunosuppressive agents used to reduce frequency of relapses. a. Must monitor long term effects, be alert for signs and symptoms of infection, hypertension, kidney dysfunction 2. Prednisone, corticosteroids used to reduce inflammation in acute exacerbations. a Must monitor for risk of infection, hypervolemia, hypernatremia, hypokalemia, hyperglycemia, GI bleeding 3. Dantrolene, tizanidine, baclofen, diazepam (valium), Antispasmodics used to treat muscle spasticity. a. Must observe for muscle weakness

Myasthenia Gravis def: progressive autoimmune disease that produces severe muscular weakness, characterized by periods of exacerbation and remission, caused by antibodies that interfere with transmission of acetylcholine at neuromuscular junction Risk factors: rheumatoid arthritis, scleroderma, lupus, co-existing autoimmune disorder, hyperplasia of thymus gland Factors that trigger exacerbation: stress, pregnancy, infection, increases in body temp Symptoms: 1. progressive muscle weakness 2. diplopia (double vision) 3. difficulty chewing and swallowing 4. respiratory dysfunction 5. bowel and bladder dysfunction 6. poor posture 7. fatigue after exertion 8. impaired respiratory status 9. decreased swallowing ability Diagnostic testing: tensilon testing, electromyography Nursing care: maintain patent airway, assess swallowing to prevent aspiration, energy conservation, have client sit upright Medications: 1. anticholinesterase agents, first line of thearpy 2. pyridotigmine (Mestinon and neostigmine (Prostigmin), used to increase muscle strength, inhibits breakdown of acetycholine a. must assess for history of seizures 3. immunosuppressants such as azathioprine (Imuran) and prednisone

Therapeutic procedures: 1. Plasmapheresis: removal of circulating antibodies 2. Thymectomy: removal of thymus gland

Guillain-Barre Syndrome def: develops in relation to acute destruction of the myelin sheath of peripheral nerves due to autoimmune disorder, results in weakness and paralysis. Three stages exist: 1. Initial period: 1 to 4 weeks, onset of symptoms until neurological deterioration stops 2. Plateau period: several days to 2 weeks, no deterioration, no improvement occurs 3. recovery period: 4 to 6 months up to 2 years, remyelination and return of muscle strength Risk factors: recent history of acute illness, viruses, vaccination, surgery Symptoms: 1. increasing weakness with no recollection of injury 2. report of virus within previous 1 to 3 weeks 3. acute progressive muscle weakness or paralysis 4. muscle flaccidity without muscle atrophy 5. paresthesias, creeping/crawling sensations across skin 6. cranial nerve symptoms (diplopia, facial weakness, dysarthria, dysphagia) 7. decreased/absent deep tendon reflexes Diagnostic Procedures: 1. EMG and nerve conduction velocity 2. WBC, because leukocytosis can develop 3. Lumbar puncture: shows increase in protein within the cerbrospinal fluid without an increase in cell count Nursing Care: 1. monitor respiratory status 2. keep head of bed at 45 degrees, turn and cough, deep breath, incentive spirometer as indicated 3. monitor heart rhythms for irregularities and bradycardia 4. monitor blood pressure 5. assess for dysarthria (difficulty in articulating words) 6. assess for difficulty swallowing and choking 7. assess for pain 8. prevent skin breakdown Medications: 1. Morphine: for pain and paresthesias 2. IV immunoglobulin: given to suppress attack on immune system 3. Neurontin (Gabapentin): Given for neuropathic pain Therapeutic Procedures: Plasmapheresis: blood is removed from body, ran through a separator so circulating antibodies can be removed

Trigeminal neuralgia Def: condition of fifth cranial nerve, pain is described as unilateral shooting and stabbing sensation (note: unilateral nature of the pain is an important feature), cause is unknown (demyelination of trigeminal root is suspected however) symptoms: 1. unilateral pain of face

2. facial twitching 3. symptoms can appear at any time or stimulation of nerve root such as washing of face or brushing teeth. Avoidance of these normal behaviors are also a tool for diagnosis. Medications: antiseizure agents, such as carbamazepine (Tegretol): relieve pain by reducing number of impulses on that nerve. gabapentin and baclofen are also used for pain control Surgical Management: basically these are options that can manipulate the nerve root so pain is relieved 1. microvascular decompression of the trigeminal nerve 2. radiofrequency thermal coagulation 3. percutaneous balloon microcompression Nursing care: 1. helping recognize factors that cause pain 2. food and fluids at room temp 3. recognize anxiety, depression, insomnia are likely in these patients Bells palsy def: facial paralysis caused by unilateral inflammation of seventh cranial nerve, results in weakness and paralysis of facial muscles on affected side of face (cause unknown) nerve becomes compressed to the point of damage, can produce necrosis of the nerve, result is facial distortion, spontaneous recovery occurs typically within 3 - 5 weeks Medications: objective are to maintain muscle tone and prevent denervation 1. corticosteroid therapy such as prednisone: reduce inflammation and edema, which reduces vascular compression 2. analgesic agents for facial pain Nursing care: 1. during paralysis: protection of eye from injury (frequently the eye does not close) 2. massaging face after nerve sensitivity has diminished, and face exercises Huntingons disease Def: chronic, progressive, hereditary disease of nervous system, results in progressive involuntary choreiform movement and dementia involves premature death of cells of basal ganglia (which controls movement) Symptoms: 1. chorea: abnormal involuntary movements 2. intellectual decline 3. emotional disturbance Diagnostic findings: 1. clinical presentation 2. positive family history 3. exclusion of other causes Medications: no cure or reversal possible, medications are directed at reducing chorea 1. Navane and haldol block dopamine receptors which improves chorea 2. note Akathisia (motor restlessness) is possible in the overmedicated, and may be overlooked as the disease itself.

Amytrophic Lateral Sclerosis def: loss of motor neurons in anterior horns of spinal cord and lower brain stem, as neuron cells die, degeneration may occur to both upper and lower motor neuron systems Death occurs within 3 to 5 years of initial symptoms from respiratory failure Symptoms: depend on location of affected motor nuerons 1. fatigue 2. cramps 3. twitching 4. incoordination 5. reflexes are over reactive 6. difficulty in speaking, swallowing 7. death usually occurs as a result of infection, respiratory failure, aspiration Diagnostic test: 1. signs and symptoms 2. elctromyography and muscle biopsy 3. MRI shows high signal intensity in the corticospinal tracts (this differentiates ALS from motor neuropathy) Medications: 1. riluzole (Rilutek): glutamate antagonist, slows deterioration of motor neurons 2. Lioresal, Dantrium, Valium: used to control spasticity which causes pain Nursing Care: 1. mostly managed at home 2. maintain patent airway 3. assess swallow reflex, thicken fluids as needed 4. effective communication through speech therapy as indicated Parkinsons disease Def: progressively debilitating disease that grossly affects motor function from overstimulation by acetylchline. four primary factors: 1. tremor 2. muscle rigidity 3. bradykinesia 4. postural instability stage 1: unilateral shaking or tremor of one limb stage 2: bilateral limb involvement occurs making walking and balance difficult stage 3: physcial movement slow down significantly, affecting walking more stage 4 tremors may decrease but akinesia and rigidity make day to day tasks difficult stage 5: client unable to stand or walk, is dependent for all care, may exhibit dementia assessment findings: 1. stooped posture 2. slow, shuffling gait 3. slow speech 4. tremors 5. muscle rigidity 6. bradykinesia 7. mask like expression 8. difficulty chewing swallowing 9. drooling 10. dysarthria

Diagnostic tests: no definitive diagnostic procedures Nursing care: 1. monitor swallowing and maintain adequate nutrition 2. maintain client mobility for as long as possible 3. promote client communication for as long as possible 4. monitor clients mental and cognitive status Medications: 1. Dopominergics, such as levodopa, increase levels of dopamine in the brain a. monitor for wearing off phenomenon and dyskinesias 2. dopamine agonists: such as bromocriptine, activate the release of dopamine a. monitor for orthostatic hypotension 3. anticholinergics: such as beztropine(Cogentin), help control tremors and rigidity a. monitor for anticholinergic effects (dry mouth, contstipation, urinary retention 4. antivirals: such as amantadine(Symmetrel, stimulate release of deopmain and prevent its reuptake a. monitor for swollen ankles, discoloration of skin b. may experience atropine-like effects