1. Copyright © 2013, 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. Block 2 Neuro Concepts CARE OF PATIENTS WITH PROBLEMS OF THE CENTRAL NERVOUS SYSTEM: THE BRAIN BLOCK 2 FEATURED DISORDERS SEIZURES & EPILEPSY MENINGITIS & ENCEPHALITIS

2. Copyright © 2013, 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. Seizures vs. Epilepsy  Seizure: A seizure is 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. Generalize or Partial  Epilepsy: is defined by the National Institute of Neurological Disorders and Stroke as two or more seizures experienced by a person; manifest with different characteristics- look up tonic- clonic, absent, etc.  Types: Primary or idiopathic: no known cause, but genetic link Secondary: known cause for example, tumor, injury, infection

3. Copyright © 2013, 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. What is the Role of Neurons?  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.

4. Copyright © 2013, 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. Seizure/Epilepsy Diagnosis  EEG  CT or MRI  Labs

5. Copyright © 2013, 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. Seizure Risks  May result from:  Metabolic disorders  Acute alcohol withdrawal  Electrolyte disturbances  Heart disease  High fever  Stroke  Substance abuse

6. Copyright © 2013, 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. Seizure Assessment  Questions:  Ask patient or relative how many, how long they last and any patterns  Describe movement  Any aura?  Medications  Any risks?

7. Copyright © 2013, 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. Seizure Precautions  Oxygen  Suction equipment  Airway  IV access  Side rails up  Nothing inserted into mouth

8. Copyright © 2013, 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. Seizure Management  Depends on type of seizure  Observation and documentation  Patient safety  Side-lying position  No restraints  Nothing in mouth

9. Copyright © 2013, 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. Acute Seizure Management  Lorazepam (Ativan)  Diazepam (Valium)  IV phenytoin (Dilantin) or fosphenytoin (Cerebyx)

10. Copyright © 2013, 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. Drug Therapy  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

11. Copyright © 2013, 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. Surgical Management  Nerve stimulation (VNS)  Conventional surgical procedures  Anterior temporal lobe resection

12. Copyright © 2013, 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. Status Epilepticus  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

13. Copyright © 2013, 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. Patient & Family Education  Compliance with medication  Discrimination prohibited (ADA)  Alternative employment may be needed

14. Copyright © 2013, 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. Meningitis  Meningitis: is an inflammation of the meninges that surround the brain and spinal cord  Block 2:  Viral  Bacterial

15. Copyright © 2013, 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. Physical Assessment & Clinical Manifestations  Question for 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- look up what these are  Decreased mental status  Focal neurological deficits  GI symptoms  Nausea and vomiting

16. Copyright © 2013, 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. Laboratory Assessment of Meningitis  CSF analysis (lumbar puncture)  CT scan  Blood cultures  CBC  X-rays to determine presence of infection

17. Copyright © 2013, 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. Key Assessment  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

18. Copyright © 2013, 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. Key Assessment Continued  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)

19. Copyright © 2013, 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. Drug Therapy  Broad-spectrum antibiotic (one example- Vancomycin)  Hyperosmolar agents (example- mannitol)  Anticonvulsants (control seizures)  Steroids (controversial)  Barbiturates (drug induced coma)  Prophylaxis antibiotic treatment for those in close contact with meningitis-infected patient

20. Copyright © 2013, 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. Patient Care  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

21. Copyright © 2013, 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. 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

22. Copyright © 2013, 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. Encephalitis  Pathophysiology-refer to lecture prep  Causes-refer to lecture prep  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- 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

23. Copyright © 2013, 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. Hemorrhagic Encephalitis