Block 2 Neuro Concepts CARE OF PATIENTS WITH PROBLEMS OF THE CENTRAL NERVOUS SYSTEM: THE BRAIN BLOCK 2 FEATURED DISORDERS SEIZURES & EPILEPSY MENINGITIS & ENCEPHALITIS

 Neurons (also called nerve cells and nerve fibers) are electrically excitable cells in the nervous system that function to process and transmit information  Neurons are the core components of the brain, spinal cord and peripheral nerves  Motor Neurons cause movement or mobility  Sensory Neurons cause sensation  Some neurons process information and some retain  Impulses from one neuron to another may cause excitation or inhibition What is the Role of Neurons?

Basic Structure of Neurons

Speed Neuron Review  When a neuron receives an impulse from another neuron, the impulse may be excitation of inhibition as mentioned in previous slide  Afferent neurons also known as sensory neurons, are specialized to send impulses toward the CNS away from the PNS  Efferent neurons are motor nerve cells that carry signals from the CNS to the cells in the PNS  Impulses are transmitted to their destinations through the spaces between neurons  Two distinct types of synapses are neuron-to-neuron or neuron-to-muscle (or gland)

 Seizure: an abnormal, sudden, excessive, uncontrolled electrical discharge of neurons within the brain that may result in a change in level of consciousness (LOC), motor or sensory ability, and/or behavior, generalized or partial  Epilepsy: is defined by the National Institute of Neurological Disorders and Stroke as two or more seizures experienced by a person- distinguished by different characteristics  Epilepsy Type Primary or idiopathic: no known cause, but genetic link Secondary: known cause for example, tumor, injury, infection Seizure versus Epilepsy

 EEG  CT or MRI  Labs Seizure/Epilepsy Diagnosis

 May result from:  Metabolic disorders  Acute alcohol withdrawal  Electrolyte disturbances  Heart disease  High fever  Stroke  Substance abuse Seizure Risks

 Ethanol is a CNS depressant  Euphoria & behavior excitation at low levels  Acute intoxication at higher levels causes drowsiness, ataxia, slurred speech, stupor and coma  Short-term effects of ETOH are actions on certain ions  Prolonged consumption leads to tolerance & physical dependence because ion function changes  Abrupt cessation of ETOH with prolonged ETOH consumption unmasks the ion changes & leads to ETOH withdrawal syndrome  Withdrawal includes blackouts, tremors, muscular rigidity, delirium tremors AND SEIZURES Enrichment Info

 Questions:  Ask patient or relative how many, how long they last and any patterns  Describe movement  Any aura? (pre-ictal phase)  Medications  Any risks? Seizure Assessment

 Oxygen  Suction equipment  Airway  IV access  Siderails up Seizure Precautions

 Depends on type of seizure  Observation and documentation  Patient safety  Side-lying position  No restraints  Nothing in mouth Seizure Management

 Lorazepam (Ativan)  Diazepam (Valium)  IV phenytoin (Dilantin) or fosphenytoin (Cerebyx) Acute Seizure Management

 Evaluate most current blood level of medication, if appropriate  Be aware of drug-drug/drug-food interactions  Maintain therapeutic blood levels for maximal effectiveness  Do not administer warfarin with phenytoin  Document and report side/adverse effects Drug Therapy

 Nerve stimulation (VNS)  Conventional surgical procedures  Anterior temporal lobe resection Surgical Management

 Prolonged seizures that last more than 5 min or repeated seizures over course of 30 min –  Establish airway  ABGs  IV push lorazepam or diazepam  Rectal diazepam  Loading dose IV phenytoin Status Epilepticus

 Compliance with medication  Discrimination prohibited (ADA)  Alternative employment may be needed Patient & Family Education

 Meningitis: is an inflammation of the meninges that surround the brain and spinal cord  Block 2:  Viral  Bacterial Meningitis

 Question predisposing history: infections, procedures or injuries?  General symptom  Fever  Neurological symptoms  Headache  Photophobia  Indications of increased ICP  Nuchal rigidity  Positive Kernig’s, Brudzinski’s signs  Decreased mental status  Focal neurological deficits  GI symptoms  Nausea and vomiting Physical Assessment & Clinical Manifestations

 CSF analysis (lumbar puncture)  CT scan  Blood cultures  CBC  X-rays to determine presence of infection Laboratory Assessment of Meningitis

 Priority: Decreased (or change in) level of consciousness Priority: Disoriented to person, place, and year  Pupil reaction and eye movements:  Photophobia  Nystagmus  Abnormal eye movements  Motor response: Normal early in disease process  Hemiparesis, hemiplegia & later decreased muscle tone possible Key Assessment

 Cranial nerve dysfunction, especially CN III, IV, VI, VII, VIII  Memory changes: Attention span (usually short)  Personality and behavior changes  Bewilderment  Severe, unrelenting headaches  Generalized muscle aches and pain  Nausea and vomiting  Fever and chills  Tachycardia  Red macular rash (meningococcal meningitis) Key Assessment Continued

 Broad-spectrum antibiotic (one example- Vancomycin)  Hyperosmolar agents (example- mannitol)  Anticonvulsants (control seizures)  Steroids (controversial)  Barbituates (drug induced coma)  Prophylaxis antibiotic treatment for those in close contact with meningitis-infected patient Drug Therapy

 ABC  VS & Neuro Checks  Cranial Nerve Assessment- particularly III, IV, VI, VII, and VIII  Meds  I & O  Labs  Bedrest & HOB 30 degrees  Nurse safety- standard & droplet isolation with bacterial meningitis Patient Care

Encephalitis  Inflammation of brain tissue and surrounding meninges  Affects cerebrum, brainstem and cerebellum  Viral agent most common but also bacteria, fungi, or parasites (example malaria is a parasite transmitted form bites of mosquitos)  Virus travels to CNS via bloodstream, along peripheral or cranial nerves or meninges (varicella zoster)  Inflammatory response but no exudate  Nursing-  Drug therapy- no specific meds for aborviruses or enteroviruses, but acyclovir is used for herpes encephalitis  Complications-permanent neuro damage

 Pathophysiology-refer to lecture prep notes  Causes-refer to lecture prep notes  Preventative measures-control mosquitos  Physical assessment- The patient may be lethargic, stuporous, or comatose  Mental status changes are more extensive in the patient with encephalitis than with meningitis. Changes include acute confusion, irritability, and personality and behavior changes (especially noted in the presence of herpes simplex)  Nursing-  Drug therapy- no specific meds for aborviruses or enteroviruses, but acyclovir is used for herpes encephalitis  Complications-permanent neuro damage Encephalitis

Encephalitis Management  Nursing Management: similar to meningitis but meds are different  Drug therapy- no specific meds for aborviruses or enteroviruses, but acyclovir is used for herpes encephalitis  Complications-permanent neuro damage

Hemorrhagic Encephalitis