CCRN/PCCN Review Neurology - FOCUS CONFERENCES · 3/17/2014 12 MG Etiology •T cells and various...
Transcript of CCRN/PCCN Review Neurology - FOCUS CONFERENCES · 3/17/2014 12 MG Etiology •T cells and various...
3/17/2014
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CCRN/PCCN Review Neurology
Cynthia Bautista, PhD, CNRN, SCRN, CCNS, ACNS-BC
Neuroscience Clinical Nurse Specialist
Yale-New Haven Hospital
Questions on Exam
• 12% CCRN Neurology
– 18 questions
• 5% PCCN Neurology
– 5-6 questions
– Cerebrovascular Malformation
– Encephalopathy
– Intracranial Hemorrhage
– Seizures
– Stroke Copyright Nursing Brains, LLC
Neuro Anatomy
• Cerebrum
•Frontal Lobe •Motor, personality, Brocca speech
•Temporal Lobe •Seizure, Wernicke speech, hearing
•Parietal Lobe •Sensation
•Occipital Lobe •Vision
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Cerebellum and Brain Stem
• Cerebellum
– Coordination and Balance
• Brain Stem
– Cranial Nerves
– Motor/Sensory Pathways
– “RESPIRATORY”/Cardiac Center
– Reticular Activating System (alert/awake)
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Neurological Assessment
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Level of Consciousness Glasgow Coma Scale
• Eye Opening
– 4 - Spontaneous
– 3 - To Speech
– 2 - To Pain
– 1 – None
• Verbal Response
– 5 - Oriented
– 4 - Confused
– 3 - Inappropriate Words
– 2 - Inappropriate Sounds
– 1 - None
• Motor Response
– 6 - Obeys Commands
– 5 - Localizes
– 4 - Withdraws
– 3 - Abnormal Flexion
– 2 - Abnormal Extension
– 1 -None
“BEST INDICATOR FOR CHANGE IN NEUROLOGICAL FUNCTION”
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Cranial Nerves
CN III: Pupil reaction, ipsilateral to injury CN V, VII, IX, X, XII: Eating, prevent aspiration
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Motor Response
• Motor Strength Scale
– Movement against Gravity and Resistance
• 5- Normal movement
• 4- Movement against moderate gravity and resistance
• 3- Movement against gravity only
• 2- Movement but not against gravity
• 1- Muscle contraction
• 0- No movement
“CONTRALATERAL TO INJURY”
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Vital Signs
• Temperature
– Hyperthermia, hypothermia
• Pulse
– Bradycardia
• Blood Pressure
– Elevated systolic, widen pulse pressure
• Respirations
– Central Neurogenic Hyperventilation, Apneusis, Cluster breathing, Ataxic breathing, Chenyne Stokes
“CUSHINGS TRIAD – ICP LATE SIGN”
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Abnormal Respiratory Patterns
Cheyne-Strokes
Central Neurogenic Hyperventilation
Apneustic
Cluster Breathing
Ataxic Breathing
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Head Trauma
Mild Head Injury
• Concussion – Violent shaking of the brain
– Postconcussion Syndrome • Confusion, forgets things, loses temper,
impulsive, has a harder time learning, problems at work/school, personality change
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Contusion
• Bruising of brain tissue
• Frontal or temporal lobe
• Maximum edema occurs up to 36 hours
• Coup – Contrecoup Injury
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Diffuse Axonal Injury (DAI)
• Severe mechanical disruption of neuronal pathways (shearing injury)
• Rapid acceleration and deceleration
• Immediate/prolonged unconsciousness
• MRI to diagnose
• High morbidity rate
• Vegetative care
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Penetrating
• Most lethal brain injury
• 90% mortality rate
• Handgun
• Rifle
• Shotgun
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Penetrating Head Injury Outcomes
• Presenting Neuro Status – Awake = survive
– Comatose = death
• Path of Bullet – Single hemisphere = survive
– Bilateral hemispheres = death
• Caliber & Velocity of Bullet – Small & slow = survive
– Large & fast = death
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Penetrating Head Injury Outcomes (con’t)
• Time to Treatment
– Quick arrival to ED= survive
– Delay in arrival to ED= death
• Nature of Shooting
– Assault = survive
– Suicide = death
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Basilar Skull Fracture
Anterior Fossa
•Rhinorrhea
•Anosmia
•Raccoon eyes
•Drip Pad for rhinorrhea
Middle Fossa
•Otorrhea
•Decreased hearing
•Battle signs (24-48° after injury)
•Bedrest
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Interventions
• Airway – Breathing
– Oxygenate, ventilate (PCO2 30-35)
– Suction only when necessary (2 passes)
• Circulation
– Maintain CPP > 60mmHg
– Normovolemia
• Drain CSF
• Control stimulation
– Narcotic, sedatives, barbiturates
• Regulating nursing activities
• Thermoregulation
– Normothermic (96.8° – 98.6°F, 36°-37°C)
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Hydrocephalus
Hydrocephalus Pathophysiology
• Obstructive Hydrocephalus
– Obstruction of ventricular system
– Treat with ventriculostomy, treat edema
• Communicating Hydrocephalus
– Interference with reabsorption of CSF
– Treat with ventriculostomy, treat hemorrhage
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Hydrocephalus Assessment & Management
• Assessment
– LOC, pupils, motor strength
• Management
– Treat the cause
– Ventriculostomy
– Lumbar drain
– VP Shunt
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Intracranial Hemorrhage PCCN PAY ATTENTION!!!!
Cerebral Aneurysm
• “Worst headache of my life”
• Hunt and Hess
– Grade I- minimal headache
– Grade II- mod/severe HA, min neuro deficits
– Grade III- Drowsy, mild neuro deficits
– Grade IV- Stuporous, mild/severe hemiparesis
– Grade V- comatose, posturing
• CT Scan
• MRI
• Cerebral angiogram
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Aneurysm Management
Endovascular Procedure
•Coils
•Stents
Surgical Treatment
•Clipping
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Aneurysm Management
• Prevent Rebleeding
– Decrease environmental stimuli
– Avoid valsalva
– SBP < 150 mmHg (pretreatment)
– Administer antihypertensives (Labetalol)
• Prevent Vasospasm
– SBP 160 – 180 mmHg (posttreatment)
– Calcium channel blocker (Nimodipine)
– Triple H therapy
• Hypertension, Hypervolemia, Hemodilution
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SAH Complications
• Vasospasm
– Abnormal narrowing of artery
– Occurs day 3 to 2-3 weeks after rupture
– Peaks 7-14 days
• Rebleeding
– Lysis of clot or hypertension
– Occurs 24 hours or 7-10 days after rupture
• Hydrocephalus
– Due to SAH, obstructing arachnoid villi
– Place ventriculostomy, VP Shunt
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Arterial Venous Malformation
• Congenital malformation
• Detected age 20 – 50 yrs
• Vessels of high pressure flow into vessels of low pressure
• Vessels rupture - headache
• Treatment
– Embolization
– Surgical removal
– Radiation
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Epidural Hematoma
• Arterial bleed
– Temporal bone
– Middle meningeal artery
• Unconscious Conscious Unconscious
• Medical emergency
– Evacuation of hematoma
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Subdural Hemorrhage
• Venous bleed – Acute
• Symptoms occurs < 48 hours from injury
– Subacute • Symptoms occur 48 hours to 2
weeks from injury
– Chronic • Symptoms occur > 2 weeks
from injury
• Elderly and alcoholics
• Patient on anticoagulants
– Evacuation of hematoma
– Allow to reabsorb on own
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Intracranial Hemorrhage
• Subarachnoid Hemorrhage – Severe head injury
• Intraventricular Hemorrhage – Secondary to SAH
– Extension of ICH
• Intracerebral Hemorrhage – Related to contusion
– Frontal & temporal lobes
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Stroke PCCN PAY ATTENTION!!!!
Ischemic Stroke
• Accounts for 80% of strokes
• Caused by thrombosis or embolism
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Signs/Symptoms F-A-S-T
– F = FACE numbness or weakness especially one side of body
– A = ARM numbness or weakness one side of body
– S = SPEECH slurred or difficulty speaking or understanding
– T = TIME to immediately call 9-1-1 and note
time symptoms started or last time person was seen normal
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Ischemic Stroke Management
• Oxygenation (pulse ox >92%)
• BP Control ( 185/110)
– Antihypertensives (labetalol)
• Glucose control
• Thrombolytics (t-PA)
– Time of symptom onset (3hours), CT Scan, weight, 0.9mg/kg, bolus 10% of total dose over 1”, remaining dose over 60”
– Monitor BP and Neuro exam
• Antiplatelets (ASA, Plavix, Aggrenox)
• Anticoagulants (Coumadin)
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Hemorrhagic Stroke
• Accounts for 20% of strokes
• Caused by vessel rupture
• Hypertension common cause
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Hemorrhagic Stroke Signs and Symptoms
• Severe headache
• Loss of consciousness
• Contralateral hemiparesis/hemiplegia
• Nausea, vomiting
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Hemorrhagic Stroke Management
• Maintain airway
• BP Management
– Labetalol, Nicardipine
• Control ICP
– HOB 30 degrees, Hyperventilate, Mannitol
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Encephalpathy PCCN PAY ATTENTION!!!!
Pathophysiology
• Neurologic degeneration
– Direct or indirect effect on brain
• Build up of toxic metabolic products
• Structural changes
• Changes in blood flow to brain
• Changes in electrical activity
• Change in supply of neurotransmitter substance
• Not a disease, results from other disease
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Hypoxia/Anoxia
• Airway obstruction
• Arterial obstruction
• Cardiac arrest
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Hypoxic-Ischemic
• Embolic
• Thrombotic
• Fat embolism
• DIC
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Metabolic
• Hepatic
• Renal
• Electrolyte imbalance
• Progressive symptom onset
• Coma precedes motor abnormalities
• Pupil reaction preserved
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Infectious
• Menigitis
• Encephalitis
• Vasculitis
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Nursing Assessment/Management
• Assessment
– Level of consciousness - decreased
– Chronic alcohol abuse
• Management
– Monitor level of consciousness
– Treat underlying condition
– Supportive care
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Brain Death
• Irreversible cessation of entire brain, including brain stem
• Known cause of coma
• Absence of the following reflexes
– Nonreactive pupils (CN III)
– Doll’s eyes (oculocephalic)
– Cold calorics (oculovestibular)
– Corneal (CN V)
– Cough
– Gag (CN IX and X)
– Spontaneous respirations (Apnea Test)
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Seizures PCCN PAY ATTENTION!!!!!
Partial Seizures
• 80% of people who have seizures
• Starts in only one part of the cerebral cortex - it can spread
OR
• Stars focally and spreads slowly
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• Simple Partial Seizure
– Hand may shake
– Mouth may twitch uncontrollably
– Dizzy, unusual feeling, smell, sound, or sight
– Doesn’t affect consciousness
– Lasts less than a minute
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• Complex Partial Seizure
– Staring straight ahead
– Looking around
– Fidgeting with clothes
– Lip smacking
– Aimless wandering
– Automatic hand movement
– LOC is impaired
– Last 1 -2 minutes
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Generalized Seizures
• 20% of people who have seizures
• Involvement of both hemispheres
• Consciousness may be impaired
• Bilateral motor manifestations
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• Tonic - Clonic Seizure
– Grand Mal
– Entire cerebral cortex is involved
– Aura
– Tonic Phase
– Clonic Phase
– Doesn’t feel, see, or remember anything during seizure
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• Absence Seizure
– Petit Mal
– Affects layers of the cerebral cortex associated with sensory input
– Brief loss of consciousness
– Last less than 15 seconds
– Subtle signs
– More often in children
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• Myoclonic Seizure
– Generalized jerking of an extremity
– May cause patient to fall
– Less than 5 seconds
– Brief, easy to miss period of unconsciousness
– Occur in clusters
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• Atonic Seizure
– Sudden loss of muscle tone (fall)
– Loss of consciousness
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Diagnostic Evaluation
• History
• EEG
• CT/MRI
• Continuous AV/EEG Monitoring
• SPECT
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Management
• Protect patient from injury – Move objects, stay with patient,
padded bed rails, low bed
• Observe and record seizure activity – Note time of onset, body parts
involved, incontinence,
• Assess airway and breathing – Head-tilt, chin lift
– Oxygen, suction
– Turn patient on side (aspiration risk)
• Medication administration – Benzodiazepine
– Antiepileptic drug
– Drug levels
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Neuromuscular Disorders PCCN you can leave now…..
Muscular Dystrophy
• Myopathy
– Progressive muscular weakness
• Most common hereditary myopathy
• Four common types of MD
– Duchennes (DMD)
– Becker (BMD)
– Limb-Girdle Muscular Dystrophy (LGMD)
– Facioscapulohumeral (FSHD)
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Duchenne’s Muscular Dystrophy (DMD)
• Most common form of MD
• X-linked and primarily affects males
• Symptoms begin by age 5
• Death by 3rd decade
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MD Signs and Symptoms
• Toe walking and waddling gait
• Generalized hypotonia
• Weakness most pronounced in proximal lower extremities
• Gower’s sign
– Uses arms to stand and climb up body
• Pseudohypertrophy of calves
– Fatty infiltration of muscle
• Cardiomyopathy
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MD Diagnostics and Treatment
• Diagnostics
– Serum CK
– Genetic testing
– NCV, EMG
– MRI with contrast
– Muscle biopsy
– EKG, echo
• Treatment
– No definitive treatment
– Prednisone
– PT, OT
– Surgical contracture release and fusion
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Guillain-Barré Syndrome
• Description
– Inflammatory process of the nervous system
– Demyelination of peripheral nerves
– Preceded by suspected viral infection
– Accompanied by fever
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Guillain-Barré Syndrome (con’t)
• Signs/Symptoms
– Progressive, symmetrical, ASCENDING paralysis
– Difficulty in speech, swallowing, mastication (50% of cases)
– Impairment of muscles of respiration
– ASCENDING bilateral flaccid paralysis with pain
– Autonomic dysfunction (hypotension, hypertension, ileus, arrhythmias)
– No decrease in LOC
– CSF has high protein count
– EMG slowing conduction
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Guillain-Barré Syndrome (con’t)
• Management
– Supportive care (immobility & pain issues)
– Plasma exchange QOD for 10-15 days
– IVIG over 3-5 days
– Airway management
– Adequate hydration and nutrition
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Myasthenia Gravis
• Chronic, progressive autoimmune-mediated disorder
• Causes sporadic weakness of the skeletal muscles
– Primarily in the face, lips, tongue, neck and throat
– Eyelid drooping and double vision
• Muscle weakness with exercise and improved muscle strength with rest
• No cure – death (40-70%) due to respiratory arrest
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MG Etiology
• T cells and various antibodies attack and impair or destroy acetylcholine receptors at the motor end-plate of neuromuscular
junction
– Decreased number of acetylcholine receptors at neuromuscular junction
• 75% abnormal thymus
• 85% hyperplasia of thymus
• 15% thymoma
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MG Signs and Symptoms
Voluntary muscle weakness
Exacerbated by continuous use, warmer climates, and stress
Increased fatigue in the AM
Diplopia, weak EOMs, and ptosis
Dysphagia
Difficulty/weakness chewing
Difficulty swallowing / choking
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MG Diagnostic Test
• Three tests required for diagnosis Acetylcholine receptor antibody blood test
• 85% MG patients have antibody • 50% Occular MG
Anti-MuSK antibody blood test • Test negative for above then 70% MG patients have
antibody
Tensilon (edrophonium) challenge test • Give IV 2-5mg (max 10mg) (duration 5 minutes) • Increases level of acetylcholine at junction by
blocking acetylcholinesterase • Test + if muscle strength improves • False negative reported with ocular MG
Electromyography (EMG): nerve stimulation test showing speed between stimulation and muscle contraction; slowed with MG
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MG Medications
• Acetylcholinesterase inhibitors Allows ACTH to remain in neuromuscular
junction longer
Pyridostigmine (Mestinon) • 60mg every 4 hours • Time released every 12 hours
Neostigmine (Prostigmin) • 2 hour duration
– Take prior to activity, assess motor strength and secretions
– Give medications on time, within 30” of food, and with snack (GI upset)
– Atropine to tx diarrhea/salivation from acetylcholinesterase inhibitors
– Decrease dose for fasiculations due to nicotinic effects
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MG Medications
• Immunosuppressants Prednisone
• 20-60mg/day
• Give potassium chloride, calcium carbonate, vitamin D 2 to side effects
Azathioprine (Imuran) • 2-3mg/kg/day, divided doses (usually 50mg
TID)
• Takes up to 6 months for effect
Cyclophosphamide (Cytoxan) – rarely used due to toxicity
• Reboot immune system
• 1.5 - 5mg/kg/day
• Usually 100-200mg a day
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MG Treatment
• Plasmaphoresis and plasma exchange – Removes antibodies
– Short term treatment– must be done regularly
– Especially useful for crisis treatment
• Intravenous immunoglobulin (IVIG) – Pooled human gamma globulin
– Short term treatment of serious relapse
– Begin 1 – 2 weeks of onset
– 2g/kg dose over 2-5 days
– Improvement in 4-5 days, lasts about 1 month
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MG Crisis
• Respiratory support is essential in both crisis
• Myasthenic is due to infection
• Cholinergic is due to over medication
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Neurologic Infectious Diseases
Meningitis
• Description
– Inflammation of meninges
• Infective agent
– Bacterial: streptococcus pneumonia, neisseria meningitidis, H. influenzae, direct, hematogenous, CSF leak entry
– Viral: enteroviruses, arboviruses, herpes viruses, fecal-oral contamination, respiratory droplets
– Fungal: cryptococcus neoformans, open wound, mucous membrane
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Meningitis • Signs/Symptoms
– Headache, fever, nausea, vomiting
– Nuchal rigidity, Kernig’s, Brudinski's, photophobia
– Altered LOC, seizures
– CSF
• Bacterial: Cloudy, protein, glucose
• Viral: Clear, protein, normal glucose
• Management
– Control symptoms
– Antibiotics, antiviral, antifungal
– Assess LOC
– Assess for ICP
– Monitor temperature
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West Nile Virus
• Arbovirus—mosquito-borne viruses that are transmitted by blood-feeding arthropods
• Transmission
– Blood transfusion
– Organ transplantation
– Breast milk
– Intrauterine
– Laboratory acquisition
• Incubation period of 3–14 days
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West Nile Virus
• Clinical presentation of mild Infection
• 20% of people develop mild infection
• Flu-like symptoms: Fever,
headache, nausea and vomiting, backache, malaise, myalgia, maculopapular rash
• Symptoms may last 3–6 days
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West Nile Virus
• Personal protective
– Avoid being outdoors at dawn and dusk
– Wear light-colored, long clothing
– Use DEET insect repellent
– Drain standing water
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Lyme Disease
• Ticks transmit Lyme borreliosis during a blood meal
• Occurs May–Sept.
• Tick must be attached for 24–72 hrs
• Serology studies
– ELISA a positive IgM response
– Western blot used as confirmatory test if ELISA is positive
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Lyme Stage 1: Early Localized
• Skin lesions: erythema migrans at site of tick bite (60–80%)
– A “bull’s eye”—a target center, expanding central area and an outer border
• Flu-like symptoms
– Headache, malaise, fatigue, or myalgias
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Lyme Stage 2: Early Disseminated
• Acute neuroborreliosis appears weeks, months
• Malaise, fatigue, lymphadenopathy
• Nervous System:
– Meningeal signs, headache, neck stiffness, difficult concentrating, cranial nerve dysfunction, Bell’s palsy, radiculopathies, and ataxia
• Cardiac System:
– Atrioventricular block, myopericarditis, pancarditis
• Lyme arthritis
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Lyme Stage 3: Late Chronic
• Nervous system and joints continuous inflammation for >1 year
• Cognitive changes and fatigue
• Lyme encephalopathy,
polyneuropathy, and leukoencephalitis
• Chronic arthritis
• Lymphocytoma; acrodermatitis, chronica atrophicans
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Lyme Disease - Management
• Early infection
– 10–21 days antibiotics
• Doxycycline for adults and children >8 years
• Amoxicillin for children < 8 years
• Late infection
– Ceftriaxone given IV for 2–4 weeks
– Cefotaxime or penicillin G (alternative)
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Lyme Prevention
• Check for ticks after being outdoors
• Wear light clothing, long sleeves, and pants
• Apply tick/insect repellent to clothing
• Remove tick properly: grasp tick with tweezers or a piece of tissue, then pull straight out
• Human vaccine: available
– Booster injections needed every 1–3 years
• Vaccinate pets annually and check for ticks
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Bell’s Palsy
• Herpes virus causes inflammation/compression of CN VII (Facial Nerve)
• Unilateral facial weakness
• Steroids and antiviral agents
– Prednisone and acyclovir
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Brain Tumor
• Primary—unknown
• Metastatic
– 35% lung
– 20% breast
– 10% kidney
– 10% gastrointestinal tract
Brain Tumor Etiology
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• Gliomas – low-grade glioma – astrocytoma – anaplastic astrocytoma – glioblastoma multiforme
• Ependymomas
• Medulloblastoma
• CNS Lymphoma
Intra-axial Brain Tumors
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Extra-axial Brain Tumor
• Menigioma
• Metastatic
• Acoustic Neuroma (Schawonoma)
– CN VIII
• Pituitary adenoma
• Neurofibroma (neurofibromatosis)
– Peripheral nerve
– Genetic, autosomal dominate
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Brain Tumor Surgical Treatment
• Biopsy
• Craniotomy
• Stereotaxis Surgery
• Transsphenoidal/Endoscopic
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Brain Tumor Radiation Therapy
• Damages DNA of rapidly dividing cells
• 4000–6000 cGy total dose
• Duration of 4–8 weeks
• Side Effects – Skin burns, hair loss, fatigue,
local swelling
• Patient teaching includes “do not erase” markings
• Radiation necrosis
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Brain Tumor Chemotherapy
• Slows cell growth
• Cytotoxic Drugs – CCNU, BCNU, PCV, Cisplatin,
Etoposide, Vincristine, Temozolomide (Temodar)
• Side effects – Oral mucositis, bone marrow
suppression, fatigue, hair loss, nausea and vomiting, anxiety, peripheral neuropathy
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Neurosurgery
Postop Neurological Deficits
• Diminished level of consciousness
• Communication deficits – Expressive/receptive aphasia
(cerebral edema)
• Motor and sensory deficits
• Headache – First few days
– Check head dressing
– Codeine, Tylenol #3
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Postop Neurological Deficits
• Elevated temperature
– Hypothalamus, infection
– Antipyretics, hypothermia blanket
• Periocular edema
– Discoloration, ecchymosis
– Peak 48 – 72 hours (edema last 5 days, ecchymosis last 12 days)
– Cold compress
• Diminished gag/swallow (CN IX & X)
– Posterior fossa surgery
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Postop Neurological Deficits
• Visual disturbances
– Diplopia (eye patch)
– Field cuts (scan the room)
• Loss of corneal reflex
– Eye shield, tape lid shut, artificial tears
• Personality changes
– Edema, drugs, stress, surgery
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Nursing Management
• Incision
– Skin flap
– Sutures/stapes removed 7-10 days
• Supratentorial
• Infratentorial
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Nursing Management
• Head Dressing
– Turban style dressing
– MD to remove after 24 hours
– Monitor for blood or CSF
– Once removed observe incision for redness, drainage, or signs of wound infection
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Nursing Management
• Positioning Head of Bed – Elevate HOB 30 degrees
– Maintain neck in neutral position
• Turning and Positioning – No restriction
• Ambulation – Allowed OOB as soon as tolerated
– Infratentorial caution with dizziness
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Nursing Management
• Fluid and Electrolyte Balance – Maintain euvolemia
– Record I & O
– Monitor electrolyte and osmolarity
• DVT Prophylaxis – Sequential compression device
– Heparin, Lovenox
• Administer analgesics as ordered
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Postoperative Complications
• Cerebral hemorrhage
• Increased intracranial pressure – Peak 72 hours
• Tension pneumocephalus – Entry of air, posterior fossa craniotomy
– Within 24 hours to 1 week
• Hydrocephalus – Edema or subarachnoid bleeding
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Postoperative Complications
• Seizures
– Within first 7 days, focal seizure
– Prophylactic anticonvulsants
• CSF Leakage
• Meningitis
– Prophylactic antibiotics
• Wound infection
– Staphylococcal
– Redness, drainage, foul odor, elevated WBC
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