NUR 265 EXAM THREE STUDY GUIDE Case NUR 265

ENCEPHALITIS • Inflammation of the brain tissue- the ventricles. – affects the cerebrum, the brain stem, and the cerebellum • Normally caused by a virus o Herpes o Polio o Mosquito borne viruses- west Nile o Tick borne viruses o Rabies o Childhood viruses • Signs/symptoms: o High fever o Nuchal rigidity- occurs only if brain stem infected o Photophobia o Phonopobia o Headache o N/V o Altered LOC o s/s of increased ICP o fatigue o joint pain o vertigo o muscle spasms o ataxia o tremors • diagnosing: o history of  any viruses, mosquito bites, or swimming in lakes- all within the last month o lumbar puncture  analyze CSF  PCR test to detect viral DNA o EEG for brain wave activity or seizure o CT scan- hydrocephalus o Blood cultures- viruses • Assessment: o Q 4-hour neuro checks  Glasgow coma scale  Cranial nerve assessment  Change in LOC or orientation • Nursing considerations o Maintain airway o Monitor for increased ICP o Monitor for vitals and neuro frequently o Reduce stimuli- darken the room, turn down TV, put them at the end of the hall o Treat the symptoms • Treatment o Acyclovir- antiviral  Need to begin as early as possible o Prevention  Using DEET spray on self  Avoid people with herpes outbreak, etc. MENINGITIS • Inflammation of the meninges (layers covering brain) specifically the pia mater and arachnoid • Can be viral or bacterial- bacterial is much worse • People ages 16-21 have highest rate of bacterial meningitis. CDC recommends initial vaccine at 11-12 and a booster at 16. Adults are advised to get initial or booster vaccine if living in a shared residence like a dorm, traveling or residing in a foreign country which disease is common, or are immunocompromised due to a damaged or surgically removed spleen. It is safe to receive booster 8 weeks after initial vaccine incase initial vaccine status not known. • Bacterial o Occurs in outbreaks such as dorm rooms o Caused by Neisseria meningitides and streptococcus pemoniae o High mortality rate o Droplet precautions- CONTAGIOUS! o Private room • Viral o Non-contagious o Caused by mumps, HIV, herpes zoster, etc. o Low mortality rate o Standard precautions • Symptoms o Fever o Nuchal rigidity- THIS IS A CLASSIC SIGN!!! o Photophobia o Phonophobia o Headache o N/V o Change in LOC o s/s increased ICP o muscle aches o maculopapular rash o petechial rash o seizures o SIADH o SIRS/DIC • Diagnosing: o Lumbar puncture for CSF  Virus- clear, normal pressure and no organism found  Bacterial- cloudy, turbid, increased WBC! Increased protein, decreased glucose, and elevated CSF pressure o Gram stain- done to see which bacteria it is o Counterimmunoelectrophoresis (CIE)- preformed to determine presence of virus o Kerning’s sign- when doctor forces the patent’s head up, the patient’s knees will flex inward toward the core involuntarily • Nursing considerations o Bacterial patient must be on droplet precautions. Stay 3 feet away from patient unless you are wearing a mask. Teach patient and visitors about need to wear a mask o Neuro checks Q 4 hours o Monitor for ICP o Reduce stimuli o Treat the symptoms • Treatment: o Do NOT delay treatment while waiting to preform tests or obtaining test results o If meningitis’s is suspected, broad spectrum antibiotic immediately! o Decreased external stimuli- keep ICP down o Treat symptoms like fever o Prevent complications- DVT, PE, ICP, seizures. TRIGEMINAL NEURALGIA • Disorder that affects the trigeminal nerve- the fifth cranial nerve • Trigeminal nerve has 3 branches- sensation in person’s eye, upper eyelid, and forehead, lower eyelid, cheek, nostril, upper lip, and upper gum, jaw sensations lower lip, lower jaw, and muscles for chewing • Trigeminal nerve basically controls the middle of the face • Chronic pain syndrome in those areas of the face. • Pain is described as excruciating, sharp, shooting piercing, burning, etc. • Triggers- like brushing teeth, light touch stimulation, change in facial expressing (smiling), chewing, • Fear of pain stops them from talking, smiling, eating, or attending to hygienic tasks • Priority is pain management! • Medications o Carbamazepine- first choice drug- anti-epileptic. o Muscle relaxants • Percutaneous sterotactic rhizotomy- PSR- a heated needle through the inside of the patient’s cheek to trigeminal nerve and is heated up to destroy some of the nerve fiber o The entire nerve isn’t destroyed and provides long-term pain relief o Teach the patient who has had a PSR to not rub the eye on the affected side because the protective mechanism of pain will no longer warn of injury. Instead insect eye daily for redness or irritation and report to HCP of blurriness. Stress the importance of regular dental examinations because the absence of pain might not warn patient of potential dental problems. BELL’S PALSY • Acute paralysis of cranial nerve 7- facial cranial nerve. • Causes paralysis of the eye, forehead, and cheek • Pain above the ear on the affected side preceded paralysis for a few hours or days before paralysis • Acute paralysis lasts for 2-5 days o Patient can’t close eye, wrinkle forehead, smile, whistle, or grimace. Face appears almost mask like. • Caused by herpes HSV-1 laying dormant • Treatment- corticosteroids for 30-60 days. Antivirals for 7-10 days after onset of symptoms. • Nursing considerations o Because the eye doesn’t close, the cornea must be protected. Teach the patient to manually close eye at intervals. Instill tears during the day and apply ointment and patch/tape close eyelid at bedtime o May not be able to chew, swallow, etc. at meal times. Encourage patient to use the unaffected side of the mouth and eat high calorie snacks if nutritional needs aren’t met. o Use CAM therapies like massage, application of warm, moist heat and facial exercises to manage pain. BRAIN ABSCESS • Purulent infection of the brain in which pus forms in the extradural subdural, or intracerebral are of the brain. o Usually caused by bacteria- complication of meningitis. • Signs/symptoms: o Headache o Fever o Pain o Motor deficits- such as hemiplegia o Ataxia o Sensory impairment o Aphasia o Seizure activity o Visual field changes o s/s of increased ICP if severe. • Treatment o Antibiotics used if the abscess is only 2 cm deep o If abscess deeper, than a surgeon surgically drain an encapsulated abscess via a burr hole to reduce the mass effect of the lesion  In some cases, a craniotomy will be used to remove the abscess. BRAIN TUMOR • Primary brain tumors originate in the CNS and rarely metastasize to other parts of the body • Secondary tumors result from metastasis from other areas of the body. • Signs/symptoms: o Cerebral tumors  Headache- most common feature  Vomiting unrelated to food intake  Changes in vision  Hemiparesis or hemiplegia  Hypokinesia- decreased motor ability  Seizures  Aphasia  Changes in personality or behavior o Brainstem tumors  Hearing loss  Facial pain and weakness  Dysphagia- decreased gag reflex  Nystagmus  Hoarseness  Ataxia