MS

Demyelizatin of brain

Myasthenia Gravis
Abs to Ach impair transmission impulses at NMJ. AI disease Motor disorde Initially: Ocular muscles affected Diplopia and ptosis(lid lag) Facial muscle weakness Swallow n voice imp (dysphonia) General weakness Myasthenic crisis Cholinergic crisis Exacerbation of Overmedication disease, mostly w/antiCEi,severe Resp inf muscle and bulbar Muscle and bulbar weakness, weakness, May May develop resp develop resp failure failure(GI-N,V,D) Administer TENSILON if improvement ( lack of meds) it is myasthenic Administer TENSILON if no improvement (=choline crisis) give atropine

Gillian-Barre Syndrome
Acquired acute inflame dis of peripheral nerves Ascending reversible paralysis Rapid demyelization can produce resp fail, ANS dysf w/CV instability Weakness, paralysis, paresthesia, pain Diminish or abs reflexes (ascending) Bulbar weakness, cranial nerve sx Tachy, brady, HTN,hTN

Parkinson's
Progressive neurol d. (loss of pigmented cells of substantia nigra and depletion of dopamine Resting Tremors Rigidity Bradykinesia Postural changes mask like fixed gaze drooling, constip, depression retropulsion,propulsion, slurred speech Stages: Unilateral flexion of upper extremity Shuffling gait Diff ambulation Progr weakness Disability SE of antipark meds: Dyskinesia,invol mvmnt,CP, NV, Ureten, Constip, sleep dist,OhTN,dizz, confusion, depression,halucin,dry mouth(Carbidopa hightens first 2 but has less off the others) Avoid alc,protein,excess vitB6

Sx Nystagmus, b vision,

Diplopia Slurred speech, spastic weakness, Paresthesia, Emot/depression, fatigue Intention tremors (shake w/activity) Spastic bladder, Sclerotic patches on MRI Relapses and remits, exaccerbations of fatigue, weakness, numb, loss of balance

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Hx of viral illness few weeks prior Elevated protein in CSF Interferon B1,B1b and IV Methlprednisolone Plasmapharesis (hematologist) RN Teach self catheter, meds admin Avoid stress, Anticholinesterase drugs Cholinesterase inhibitors (Mestinon) tensilon (Atropine antidote) Plasmapheresis Thymectomy Adequate ventilation (intub may b needed) Airway, ABGs, Lytes, I&O, daily weights, NGT in gag absent AVOID sedatives and tranquilizers Energy conservation measures Avoid stress, infections, vigorous physical activity Plasmapharesis and IVIG Most recover completely RN Respiratory Mobility nutrition Detection of life threat compl; Resp fail, card dysrhythmias DV Changes in vital capacity ECG Levodopa (Must b on low prot diet) (I hr b4 meals) hTN, GI upset Carbidopa (Allows lower doses of levodopa by prevent.periph use of levodopa so more is avail 4 brain) Hypo/hypekinesia, psych manifestations Sinamat (combo fo both) Anticholinergic Cogentin,Artane SE:dry mouth,mydriasis(exs pupil dil) Antiviral/Parkinson: amantadineHCL SE: tremor, rigid,bradykynesia Apokyne reduces on/off responses RN Exercise, speech, nutrition, skin oral care, prevent constip, safety Standing straight, exaggerate arm swin w/Walk to promote bigger steps

Put them prone to avoid bending over

Brain Injury (Fx)

Mild Temp LOC <30 min Concussion Classic: Temp LOC <6 hrs Always accomp by some amnesia

Brain Injury (Blunt)

Post concussion syndrome Mon for diff in awakening, HA,vomit,side weakness Contusion More severe w/poss surface hemorrhage Tissue alteration and neuro deficits w/o hematoma Peak 18-36hrs,deep contusions = destruction of reticular system altering arousal Epidural (ER) Blood btwn skull n dura Brief LOC then return to lucid, hematoma expands=sudden LOC Tx - burr holes, craniotomy Hemorrhage Subdural Blood btwn dura n brain Acute 12-24hrs Subacute 48h 2days (Immediate craniotomy) Chronic weeks to months Evacuation of clot, DAI Intracerebral In the brain, trauma or not Surgery may not b poss due to location Supportive care, fluids, lytes, antiHTN meds Imme -diate coma

Primary initial damage (contusion, laceration...) Secondary damage after initial insult (c. Edema, ischemia, chem chngs) Scalp ( heavy bleeder, r4inf) Skull fx (local, persist pain, If basilar (most serious) fx nose bleed, pharynx, or ear bleed Battle sign, halo sign, raccoon eyes X-ray, CT,MRi, angiography, Elderly more prone cuz (dura more adherent to skull and meds-anticoag) Non depressed fx = no surgery Depressed fx = elevation of skull n debridement w/in

Altered LOC, Pupillary abnormalities Dizziness, lethargy, irritability , fatigue, poor concentration, low attention span, (I week after inj) Sudden onset of neuro deficits, HA, Seizures

Concussion ( arouse pt fq, but not too much , no less than q1h) Always assume cervical inj util r/o Treat edema, hypotension, hypocol,bleed, mon ICP Keep BP normal , maybe even little higher ! Resp support, seizure precaution , NG(gast motility and aspir prevent) Nutrition( hyper metabolic state) Monitor increased tem Elevate HOB, Suction w/caution, Mon ABGs, I/O, U analysis, osmolality, Reduce environmental stimuli Avoid NSAIDs to avoid hemorrhage

24hrs

Cooling blankets, avoid shivering

Spinal Cord Injury

CVA,Violence,falls sports Primary: initial trauma Secondaty:ischemia,hypoxia, bleed (reversible upto 4-6 hrs after inj)

HA
Primary: no organic cx (migrane,tension,cluster) Secondary: org cx (tumor, aneurysm) Tension (most common) Tension in muscles, constant dull pain Band around the head feeling, both sides of head, comes gradually and lasts for hrs or days Migrane: intense pulsating or throbbing pain in one area of head, sensitivity 2 light n sound N+V. prceeded bu aura Cluster: extreme pain in clusters @ the same time of day, one side of head behind the eye. Alc+smoke provokes. Peaks in 5-10 min, stays 4 hr or two,,, H&P, detailed descry of HA, Neuro exam Quiet, dark room Massage, heat for tension Sleep for migrane Stress reduction, exercise, Tension : aspirin, Tylenol, heat Migrane: Triptans (epileptic), hormone tx, sleep Cluster: O2 inhalation and triptans, lidocaine nasal spray, corticosteroids,Verapamil, Lithium.

Carpal tunnel
Nerve compression at the base of hand cx by swelling, thick or irritated tendons or others. (congenital,trauma, injury, vibrating tools,)

Heat stroke
Failure of heat regulating system Exertional: During exertion and extreme heat and humidity Hyperthermia: inadequate heat loss Sx: CNS dysfunction High temp Hot dry skin Anhydrosys hTN tachycardia

ICP
ICp =10-20 Never take temp by mouth in unconscious pt CO2 decrease = vasoconstriction (incr RR 2 decr CO2 for ICP) CO2 increase = vasodilation CCP (70-100) = MAP - ICP If CCP < 50 = permanent neuro damage Compl: brainstem hernia,DI,SIADH Early: Changes in LOC Restless, pupils, one side weakness, HA, Slow speech, delayed response Late Resp and vasomotor chx Inc BP, wide PP, tachy/Brady Cushings triad : Bradyc, bradypnea, hypertension Project. Vomit, Hemiplegia,decort,decerebr Cheyenne stokes, Loss of reflex (pupil, gag,cornea) cT, MRI, angiography, Dopple

Sx

Spinal shock: compl paralysis below inj may not b 4 life, lack of reflex n sensation Neurogenic shock: systemic reaction Decrease in BP,HR,CO Venous pooling, periph vasodilation Paralyzed parts dont perspire Autonomic dysrefexia: may occur years after injury (usually above T6 inj) Cx by distended bladder,constip, etc Severe pounding HA,incr BP,profuse diaphoresis, nasal congestion n bradyc AD:Seated position to lower BP Empty bladder, examine rectum, skin IVApresoline (ganglionic blocker) Assess: Lungs, (pulseox,ABGs, humidified O2) sensory and motor, PROM, For spinal shock, bladder dist, GI tract (const) temperature (hyperthermia) HI CAL, PROT, FIBER diet Compl: DVT, OhTN, AD,

Dx R N

Push on the area = pain - TINELS sign Neurovascular assessment is crucial after any extremity surgery Pain control RICE Prevent infection assist w/ADLs

ABCs COOLING meth: Sheets towels, sponge bath Ice to the neck, groin, axillae, chest Cooling blankets Iced lavage of stomach Cold bath IV to replace fluid losses AVOID hypothermia

Fq neuro checks, GCS, perrla, cranial nerves, VS Airway, resps, Elevate HOB to promote venous drainage, Avoid hip flex, valsalva, abd distent 2 avoid inc ICP, Calm, quiet atmosphere, I/O Surgery Craniotomy/ectomy,cranioplasty, burr holes Preop: Corticosteroids, Mannitol (hyperosmotic) Antib, diazepam, Baseline neuro Postop: Detect and reduce cerebral edema (peaks in 24-36 hrs), pain, seizures, FQ mon Vs, neuro, ABG, LOC, bleed, Avoid hypoxia or hypercapnia, extreme head rotation Suction and coughing very carefully (inc ICP), turn

q2h, Announce presence - avoid startling Cool compress over eyes,

Ischemic Stroke

Hemorrhagic Stroke

Brain Surgery
Preop: CT,MRI,C.angiography Doppler Dilantin,Cerebyx, Dexamethasone Fluids may b restricted Mannitol(hyperosmotic) Lasix, Antib, Valium LOC, Neurochecks, GI, motor deficits, Shave, foley

Seizures
abnormal uncontrolled el. Discharge from neurons Cx: hypoxemia,fever,head inj, HTN,inf, tumor,drugs, allx Partial: one part of brain -simple p.- consciousness ok -complex p. no consciousness Generalized: whole brain Post convulsion: HA,fatiq, malaise,Vom, sore muscles, choking Petit mal seizure: LOC 10-20sec, no memory of it, fixed gaze,eyelid flickering,jerking

Status Epilepticus
ER! Cx: withdraw from meds,fever,infection Vigorous m. contract. + heavy metabol demand + interfere w/resp 20=30min seizure ,pt dnt come bck2consciousness

Sx

Sudden loss of function after Blood supply 2 brain distrupted Risk factors: HTN!!!,Card dis, Hi chol,Hct, Obesity, DM,oral contraceptives, smoke, alc, drugs (TIA temporary neuro defic, small CVAs=impending stroke) One sided Inc ICP numbness,weakness of Severe HA face,arm,leg Early and sudden changes in LOC Changes in LOC Vomiting Trouble speaking Cushings triad: HTN, bradycard, abn Diff resp walking,balance,coordination Sudden severe HA Perceptual disturbances HP, nwuro exam (airway, cadiac, neuro, resp) CT, ECG, MRI,dopp Prevention: Diet,exercise,tx of periodontal diseases Tx: Carotid endarterectomy, Anticoag, antiplatelet, Lovenox (sefl adm @ home) Statins, antiHTN e phase: tPA, elev HOB,Airway(may out in during aura ROM CT,cerebral angiography,LP Prevention: Control HTN Tx of vasospasm,ICP,HTN,seizures Primarily supportive BR w/sedation, O2 ACUTE phase NEURO checks, speech,swallow,eyes Respire,meningeal irritation Careful w/hot n cold water due to impaired sensorium Position prone , avoid shoulder (abduction)pain (from laying on affected side) Do not lift by affected shoulder ROM Chin tuck swallowing method Feed THICK liquid Prevent constipation Aneurysm precautions: HOB elev (2 promote v. drainage) HOB low (2 promote perfusion) Avoid active increasing ICP,BP

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Postop Supratentorial(HOB 30*)not on operative side Infratentorial (flat/prone not on back! Intubated, O2, Arterial line Manitol,dexamethasone, Tylenol, codeine, morphine, Diazepam, Opiates/sedatives (contrai) Barbituates,stool softeners, Avoid startling, cool compresses on eyes 7th CN check for eyelids closing NPO, tube feed till gag ret Mon: I&O,BG(corticost),Lytes, U osmolality (DI,SIADH) Avoid cough, sneeze,nose blow(r4 CSF leak)

Safety n protection -Maintain aiway, NO restrains -Ease pt to the floor, protect head, loosen clothing, insert oral airway during aura -Do not attempt to open jaws -if poss place pt on side w/hear flexed forward -Suction/O2 equip available Meds : Dilantin( ging hyperpl, slurred speech,conf,HA,NV, blood dyscrasias (no erthropoesis=lowFA=megaloblast anemia,use only NS if IV. Check concentration of antiseizure meds (low level suggests noncompliance) IN NYstate no driving for 1 year after seizure

Stop seizures n ensure adeq cerebral perfusion Dilantin/ Phenoytin (vitBlow=anemia) IV Diazepam,Ativan, Cerabyx (to stop ) Phenobarbitals (to stay seizure free), Propofol(GenAnast,intub) Lytes, BG, EEG IV dextrose if hypoG is the cx General anesthesia w/shortacting barbiturate (if other tx unsuccessful) Long term antiseizure tx SE: osteoporosis/malacia, hypertparathyroidism,bone fxs

Implement valsalva, non stimul envir. Prevent constipation, limit visits

Mon for Hyperthermia