CVA or Stroke An interruption of blood supply to a vital center in the brain Also called brain attack, cerebral infarction,

cerebral hemorrhage, ischemic stroke or stroke Direct Causes of Stroke Cerebral thrombosis a blood clot or plaque blocks an artery that supplies a vital brain center. Cerebral hemorrhage or aneurysm an artery in the brain bursts, weakens the aneurysm wall; severe rise in BP causing hemorrhage and ischemia. Cerebral embolism a blood clot breaks off from a thrombus elsewhere in the body, lodges in a blood vessel in the brain and shuts off blood supply to that part of the brain. Types of Stroke Ischemic stroke - when arteries are blocked by blood clots or by gradual build-up of plaque and other fatty deposits. Almost 85% of strokes are ischemic. Hemorrhagic stroke when a blood vessel in the brain breaks leaking blood into the brain. About 15% of all strokes but responsible for 30% of stroke deaths. Stages of CVA Transient ischemic attack (TIA) sudden and short-lived attack. Reversible ischemic neurologic deficit (RIND) similar to TIA, but symptoms can last up to a week Stroke in evolution (SIE) - gradual worsening of symptoms of brain ischemia. Completed stroke (CS) symptoms of stroke stable over a period and rehab can begin. Thrombolytic Therapy Anticoagulants: Sodium heparin, warfarin (Coumadin) Antiplatelets: Ticlopidine (Ticlid), clopidogrel (Plavix) Antiepileptic medications: Phenytoin (Dilantin), gabapentin (Neurontin) Diagnostic Procedures Magnetic Resonance Imaging (MRI) CT scan Magnetic Resonance angiogram Lumbar Puncture Carotid Endarterctomy Interventional Radiology Brain Tumor A brain tumor is an intracranial solid neoplasm, a tumor (defined as an abnormal growth of cells) within the brain or the central spinal canal. Tumors of the Brain Astrocytoma - The tumor arises from star-shaped glial cells called astrocytes. Brain stem glioma - The tumor occurs in the lowest part of the brain. Brain stem gliomas most often are diagnosed in

young children and middle-aged adults. Ependymoma - The tumor arises from cells that line the ventricles or the central canal of the spinal cord. Oligodendroglioma - This rare tumor arises from cells that make the fatty substance that covers and protects nerves. These tumors usually occur in the cerebrum. They grow slowly and usually do not spread into surrounding brain tissue. Signs and symptoms Headache which can be severe in the morning Anorexia Seizures and convulsions Dizziness Changes in emotional state Tinnitus and vertigo Vision changes Weakness Diagnostic exams Computerized tomography (CT) Magnetic resonance imaging (MRI) Angiogram or Arteriogram Management and treatment Surgery- is the usual treatment for most brain tumors. To remove a brain tumor, a neurosurgeon makes an opening in the skull. This operation is called a craniotomy. Radiation Therapy- Radiation therapy, also called radiotherapy, is the use of high-powered rays to damage cancer cells and stop them from growing. Chemotherapy- Chemotherapy is the use of drugs to kill cancer cells. Dementia It is the loss of mental functions such as thinking, memory, and reasoning that is severe enough to interfere with a persons daily functioning. It is irreversible when caused by disease or injury, but might be reversible when caused by drugs, alcohol, hormone or vitamin imbalances, or depression. It is not a disease itself, but rather a group of symptoms that might accompany certain diseases or conditions. Clinical Manifestations: Early Dementia Lose interest in hobbies or activities. Be unwilling to try new things. Be unable to adapt to change. Show poor judgement and make poor decisions. Be slower to grasp complex ideas and take longer with routine jobs. Blame others for stealing lost items. Moderate Dementia Be very forgetful of recent events. Memory for the distant

past seems better, but some details may be forgotten or confused. Be confused regarding time and place. Become lost if away from familiar surroundings. Severe Dementia Be unable to remember for even a few minutes that they have had, for example, a meal. Lose their ability to understand or use speech. Be incontinent. Show no recognition of friends and family. Need help with eating, washing, bathing, using the toilet or dressing. Etiology and risk Factors A family history of Dementia Down syndrome Mild cognitive impairment History of a stroke Hypertension Lack of physical activity Smoking Heavy alcohol use Unhealthy diet Treatment Anticholinesterase donepezil (Aricept), G alantamine (Reminyl) Rivastigmine (Exelon) Tacrine (Cognex Memantine (Namenda) Bell's Palsy is a paralysis or weakness of the muscles on one side of your face. Damage to the facial nerve that controls muscles on one side of the face causes that side of your face to droop. The cause of Bell's palsy is not clear. Most cases are thought to be caused by the herpes virus that causes cold sores. Symptoms of Bell's palsy Sudden weakness or paralysis on one side of your face that causes it to droop. This is the main symptom. Drooling. Eye Loss of ability to taste. Pain in or behind your ear Numbness in the affected side of your face. Increased sensitivity to sound problems, such as excessive tearing or a dry eye. Diagnosis Neurological Examination Magnetic Resonance Imaging (MRI) Blood Testing

CT scan Medical Management Corticosteroids (prednisone) Antiviral drugs (acyclovir) Analgesics Amyotrophic Lateral Sclerosis LOU GEHRIGs disease ALS is a neurodegenerative disease caused by the degeneration of motor neurons that are responsible for involuntary muscle movement, in the brain and in the spinal cord. Causes and Risk Factors It causes the death of a motor nerve cell that transmits messages from the brain to the muscle. In about 10% of the cases ALS is caused by a genetic defect, the other 90% is unknown. The nerve neurons waste away or die leading the muscle to weaken , twitch and being unable to move the arms, legs and body. As ALS weakens the patient it shuts down the nervous system messages to more and more muscles, particularly the ones that control breathing. Signs and Symptoms Muscle weakness in one or more of the following: hands, arms, legs or the Muscles of speech, swallowing or breathing Difficulty swallowing, gags or chokes easily Twitching (fasciculation) and cramping of muscles, especially those in the hands and feet Impairment of the use of the arms and legs Pain Difficulty with speech Diagnosis CSF analysis Electroencephalogram (EEG) Nerve biopsy Blood enzyme may be increased as a result of muscle atrophy Nonpharmacologic Measures Physical therapy, massage, position changes, and divertsional activities for pain control. Tube feeding via gastrostomy tube to provide adequate nutrition. Skin care to prevent incidence of pressure ulcers. Rehabilitation therapy Preventions There is no known way to prevent motor neuron disease or the dementia that goes along with it. This is an area of intense research in motor neuron diseases Multiple Sclerosis A chronic demyelinating disease that affects the myelin sheath of neurons in the central nervous system. Clinical Manifestations

 Weakness or tingling sensations of one or more extremities Vision loss from optic neuritis Incoordination that is due to cerebellar involvement Bowel and bladder dysfunction Management Prevent or postpone long-term disability Treat acute relapses Treatment aimed at disease management Treat exacerbations Symptomatic treatment Trigeminal Neuralgia Tic Douloureaux is a nerve disorder that causes abrupt, searing, electricshock-like facial pains, most commonly the pain. involves the lower face and jaw, but symptoms may appear near the nose, ears, eyes or lips. Many experts say trigeminal neuralgia is the most unbearably painful human condition. Severe pain along the course of a nerve. The pain occurs because of a change in neurological structure or function due to irritation or damage of a nerve. Signs And Symptoms Sudden sharp electrical, shocking, stinging, stabbing pain that lasts for several seconds and may repeat many times over the course of the day. Types of TN "Classic" TN Pain (TN1) It is described as: extremely sharp, throbbing, and shock-like pain. No facial numbness or weakness. There are distinct periods of remission, when there is no pain at all. Generally responds well to Tegretol, an anti-convulsive drug used to treat seizure disorders. Atypical TN Pain (TN2) It is described as: Rare. In addition to the stabbing shock-like pain, many victims experience various kinds of pain that they may describe: Throbbing Burning Crushing Pulsating Very difficult to treat. Other types of TN Trigeminal neuropathic pain (TNP)- resulting from accidental injury to the nerve or pathways in the brain of the trigeminal system. Trigeminal deafferentation pain (TDP)- with numbness (anesthesia dolorosa) resulting from intentional injury in an attempt to treat the painful disorder. Symptomatic trigeminal neuralgia (STN)- associated with

multiple sclerosis. Postherpetic neuralgia (PHN)- often in elderly patients, involving chronic facial pain following a herpes zoster (shingles) outbreak. Geniculate neuralgia (GeN)- with episodic pain deep in the ear. Glossopharyngeal neuralgia (GPN)- with tonsillar pain in the back of the throat, derived from talking or swallowing. Factors that triggers Trigeminal Neuralgia Shaving Stroking your face Eating Drinking Brushing your teeth Talking Putting on makeup Encountering a breeze Smiling Risk Factors Age - average onset of TN occurs in people 50 years of age or older Gender - women are 1.5 times more likely to develop TN than men Family history of facial pain - approximately 5% of patients report a family history of facial pain Multiple sclerosis - approximately 1% of patients with MS also suffer with TN Hypertension Medical Management Anticonvulsant - Carbamazipine (Tegretol)- drug of choice Side effects: - Dizziness - Confusion - Drowsiness - Double vision

Other medications: - Lioresal (baclofen) - Dilantin (phenytoin) - Klonopin (clonazepam) - Neurontin (gabapentin) - Lamictal (lamotrigine) - *all of them except baclofen are used to prevent seizures* Surgical Management 1. Gamma Knife Radiosurgery- method preferred for treating certain problems in the brain without making an incision. 2. Microvascular decompression (MVD)- relocating or removing blood vessels that are in contact with the trigeminal root.

3. Balloon Decompression- best choice for patients who have ophthalmic nerve pain or have experienced recurrent pain after microvascular decompression. 4. Glycerol Injection- a procedure in which the doctors inserts a needle through your face and into an opening in the base of your skull where the trigeminal nerve lies and also where the glycerol is injected. Glycerol- blocks the nerves ability to transmit pain or it may enable damaged insulation on the nerve to heal. 5. Electric current (radiofrequency thermal rhizotomy)selectively destroys nerve fibers associated with pain. Tingling sensation occurs after your awakened from sedation. 6. Rhizotomy- a procedure in which the doctors cuts the trigeminal nerve making the face numb permanently. Complications: Toxic side effects of the drugs: Liver Damage Bone marrow and blood disorders Agranulocytosis Aplastic anemia Suppression of the WBC Surgical procedures: Numbness of the face or eye that may in itself be unpleasant (anesthesia dolorosa). Corneal Abrasion Hemorrhage Infection Brainstem Damage Jaw weakness Hearing disturbances (11%) Death (rare; serious complications) Upper Motor Neuron lesion is a lesion of the neural pathway above the anterior horn cell or motor nuclei of the cranial nerves. occur in conditions affecting motor neurons in the brain or spinal cord such as stroke, traumatic brain injury and cerebral palsy. Clinical Features Initial phase - limbs flaccid - loss of tendon reflexes Several days to a week - return of motor function, but tone increases Long term - Spasticity - Hyperreflexia - Ankle & patella clonus - Babinski sign positive - extensor plantar response - Absent abdominal reflexes Etiology Amyotrophic lateral sclerosis (ALS)

Spinal cord injury (SCI) Multiple sclerosis (MS) Strokes Parkinsons disease (PD) Cerebrovascular accident Characteristics of an UMN lesion of the facial nerve Facial asymmetry Atrophy of muscles of lower portion of the face on affected side No eyebrow droop Intact folds on forehead Intact conjunctival reflex (orbicularis oculi innervation is intact) Smoothing of nasolabial folds on affected side Lips cannot be held tightly together or pursed Difficulty keeping food in mouth while chewing on affected side Diagnostic Test Electrodiagnostic tests MRI of brain and, if no cranial nerve involvement, cervical spine Electromyography Treatment 1. Baclofen 2. Tinazidine 3. Physical Rehabilitation Myestenia Gravis Diplopia (double vision) in a person with myasthenia gravis trying to open their eyes. (from Greek word myastenia "muscle "weakness", and Latin word gravis "serious") Is an autoimmune disease that presents as muscular weakness and fatigue that worsens with exercise and improves with rest. Etiology Unkown Two peaks of onset Early onset MG- at the age 20-30 y.o , women are more often affected that men Late onset MG- after age 50, men are more often affected. Complications Two major complications: - Myasthenic Crisis - Cholinergic Crisis Surgical Management Thymectomy- the surgical removal of the thymus, is essential in cases of thymoma in view of the potential neoplastic effects of the tumor. Medical Management Acetylcholinesterase inhibitors such as: -neostigmine -pyridostigmine

Immunosuppressive drugs such as: -prednisone -cyclosporine -mycophenolate mofetil -azathioprine Diagnostic test Blood Test Electomyography Chest X-ray MRI Plasmapheresis -can be used to remove the putative antibodies from the circulation Huntingtons Disease Huntingtons disease (also called Huntingtons chorea) is a rare abnormal hereditary disorder of the CNS. It is characterized by chronic progressive chorea (involuntary purposeless, rapid movements) and mental deterioration that results in dementia. Causes and Incidence Chorea, the Greek word meaning dance. It is described as involuntary movements of the body. Is a progressive neurodegenerative genetic disorder that affects muscle coordination. Results in the destruction of certain cells in the brain. Huntingdons disease is inherited as a single faulty gene on chromosome #4. Complicastions Weight loss Pneumonia Congestive heart failure Bed sore Risk Factors Hereditary (autosomal dominant gene transmission) Idiopathic Medical Management Rilutek (riluzole) Antipsychotics Antidepressants Reserpine Dopamine blockers Anticholinergic Tetrabenazine and Amand

function. Causes 1.motor vehicle accidents 2.falls 3.acts of violence 4.Sports and recreation injuries 5.Alcohol 6.Diseases Risk Factors Being male. Spinal cord injuries affect a disproportionate amount of men. In fact, females account for only about 20 percent of traumatic spinal cord injuries in the United States. Being between the ages of 16 and 30. You're most likely to suffer a traumatic spinal cord injury if you're between the ages of 16 and 30. Signs and Symptoms Loss of movement Loss of sensation, including the ability to feel heat, cold and touch Loss of bowel or bladder control Exaggerated reflex activities or spasms Changes in sexual function, sexual sensitivity and fertility Pain or an intense stinging sensation Diagnostic and examination test 1.X-rays 2.Computerized tomography (CT) scan 3.Magnetic resonance imaging (MRI 4. urinalysis 5. straight leg raise test ( SLR test) 6. Myelogram Medical Management: Methylprednisolone (Medrol) Epinephrine Surgical Management Spinal instrumentation and fusion- to provide permanent stability to the spinal cord. These procedures correct, join, solidify the level where a spinal element has been damaged or removed. BRAIN TISSUE INJURY Definition: Traumatic brain injury is damage to the brain as the result of an injury. Traumatic brain injury usually results from a violent blow or jolt to the head that causes the brain to collide with the inside of the skull. An object penetrating the skull, such as a bullet or shattered piece of skull, also can cause traumatic brain injury. Mild traumatic brain injury may cause temporary dysfunction of brain cells. More serious traumatic brain injury can result in bruising, torn tissues, bleeding and other physical damage to the brain that can result in longterm complications or death.

Spinal Cord Injury refers to any injury to the spinal cord that is caused by trauma instead of disease. spinal cord and nerve roots are damaged, the symptoms can vary widely, from pain to paralysis to incontinence. Spinal cord injuries are described at various levels of "incomplete", which can vary from having no effect on the patient to a "complete" injury which means a total loss of

Symptoms: Mild traumatic brain injury The signs and symptoms of mild traumatic brain injury (concussion) may include: Loss of consciousness for a few seconds to a few minutes No loss of consciousness, but a state of being dazed, confused or disoriented Memory or concentration problems Headache Dizziness or loss of balance Nausea or vomiting Sensory problems, such as blurred vision, ringing in the ears or a bad taste in the mouth Sensitivity to light or sound Mood changes or mood swings Feeling depressed or anxious Fatigue or drowsiness Difficulty sleeping Sleeping more than usual Moderate to severe traumatic brain injuries Moderate to severe traumatic brain injury can include any of the signs and symptoms of mild injury, as well as the following symptoms that may appear within the first hours to days after a head injury: Loss of consciousness from a few minutes to hours Profound confusion Agitation, combativeness or other unusual behavior Slurred speech Inability to awaken from sleep Weakness or numbness in the extremities Loss of coordination Loss of bladder control or bowel control Persistent headache or headache that worsens Repeated vomiting or nausea Convulsions or seizures Dilation of one or both pupils of the eyes Clear fluids draining from the nose or ears Children's symptoms Infants and young children with brain injuries may lack the communication skills to report headaches, sensory problems, confusion and similar symptoms. In a child with traumatic brain injury, you may observe: Change in nursing or eating habits Persistent crying Unusual or easy irritability Change in ability to pay attention

Inability to be consoled Change in sleep habits Sad or depressed mood Loss of interest in favorite toys or activities Causes Traumatic brain injury is caused by a blow or other traumatic injury to the head. The degree of damage can depend on several factors including the nature of the event and the force of impact. Injury may include one or more of the following factors: Damage to brain cells A severe blow or jolt A severe rotational or spinning A blast, as from an explosive device An object penetrating the skull Bleeding in or around the brain, swelling, and blood clots Common events causing traumatic brain injury include the following: >Falls >vehicle-related collisions >violence >sport injuries >explosive blasts and other combat injuries Risk factors The people most at risk of traumatic brain injury include: Children, especially newborns to 4-year-olds Teenagers, especially those 15 to 19 years of age Adults over 65 COMPLICATIONS: Altered consciousness > coma >vegetative state > minimally conscious state > locked-in syndrome Seizures Infections Nerve damage Cognitive problems Behavioral and emotional changes Sensory problems Degenerative brain diseases TEST AND DIAGNOSIS Glasgow Coma Scale Imaging tests >CT scans > MRIs Intracranial pressure monitor MEDICAL INTERVENTION

 Diuretics Anti-seizures drug Coma- inducing drug Surgery Removing clotted blood (hematomas). Repairing skull fractures. Opening a window in the skull. Nursing Diagnosis Risk for injury related to complications of head injury. Preventing head injuries in children The following tips can help children avoid head injuries: Install safety gates at the top of stairs Install child-height handrails on staircases Keep stairs clear of clutter Install window guards to prevent falls Put a nonslip mat in the bathtub or shower Use playgrounds that have shock-absorbing materials on the ground Don't let children play on fire escapes or balconies Assess for cause of restlessness - Often present as patient emerges from coma - May be due to hypoxia, fever, pain, full bladder Use padded side rails or wrap hands in mitts - Avoid restraints as straining against them increases ICP Minimize environmental stimuli - Low lights, limit visitors, speak calmly - Orient patient frequently - Ineffective airway clearance related to accumulation of secretions and decreased LOC Maintain patient airway - - Suction carefully - Discourage coughing (causes increase in ICP) - Elevate HOB 30 degrees - Guard against aspiration - Monitor ABGs to assess ventilation - Risk for fluid volume deficit related to dehydration procedures and decreased LOC Monitor electrolytes - Brain damage can produce metabolic and hormonal dysfunctions Monitor intake and output Monitor IV fluids carefully Monitor urine for acetone, osmolality Record daily weights - Altered cerebral tissue perfusion related to increased intracranial pressure Position patient to reduce ICP :

head in midline position to promote venous drainage - Elevate HOB 30 degrees - Avoid extreme rotation or flexion of neck - Avoid extreme hip flexion Prevent straining - Stool Softeners - High Fibre diet Space Nursing activities Maintain calm atmosphere, reduce stimuli - Altered cerebral tissue perfusion related to increased intracranial pressure Position patient to reduce ICP : head in midline position to promote venous drainage - Elevate HOB 30 degrees - Avoid extreme rotation or flexion of neck - Avoid extreme hip flexion Prevent straining - Stool Softeners - High Fibre diet Space Nursing activities Maintain calm atmosphere, reduce stimuli GuillainBarr Syndrome (GBS) Acute condition associated with progressive muscle weakness and paralysis. It is an autoimmune disorder in which the body's immune system attacks its own nervous system. Weakness in their legs Blurred vision Lower cranial nerves may be affected Temperature sensation is usually mild Respiratory difficulties Oropharyngeal dysphagia Palpitations HERNIATED INTERVERTEBRAL DISK Lumbar Radiculopathy Cervical Radiculopathy A herniated disc is a fragment of the disc nucleus which is pushed out of the outer disc margin, into the spinal canal through a tear or "rupture. In the herniated disc's new position, it presses on spinal nerves, producing pain down the accompanying leg. This produces a sharp, severe pain down the entire leg and into the foot. Symptoms of Herniated Lumbar Disk: Muscle spasm Muscle weakness or atrophy in later stages Pain radiating to the buttocks, legs, and feet

 Pain made worse with coughing, straining, or laughing Severe low back pain Tingling or numbness in legs or feet RISK/PREDISPOSING FACTORS/CAUSES: Strenuous physical activity Congenital conditions that affect the size of the lumbar spinal canal These disks may herniate (move out of place) or rupture from trauma or strain. Radiculopathy refers to any disease that affects the spinal nerve roots. A herniated disk is one cause of radiculopathy (sciatica). DX. Spine x-ray may be done to rule out other causes of back or neck pain. However, it is not possible to diagnose a herniated disk by spinal x-ray alone. Spine MRI or spine CT will show spinal canal compression by the herniated disk. EMG may be done to determine the exact nerve root that is involved. Myelogram may be done to determine the size and location of disk herniation. tx short period of rest with pain and antiinflammatory medications followed by physical therapy Most people who follow these treatments will recover and return to their normal activities. A small number of people need to have further treatment, which may include steroid injections or surgery. Meds Nonsteroidal anti-inflammatory medications (NSAIDs) and narcotic painkillers will be given to people with a sudden herniated disk caused by some sort of injury (such as a car accident or lifting a very heavy object) that is immediately followed by severe pain in the back and leg. Pain, acute/ chronic Interventions: a.) assess reports of pain, noting location, duration, precipitating/aggravating factors. ask patient to rate on scale of 010 (or other scale as appropriate). Rationale: * helps determine choice of interventions and provides basis for comparison and evaluation of therapy.

b.) maintain bedrest briefly during acute phase. place patient in semi-fowlers position with spine, hips, knees flexed; supine with/without head elevated 1030 degrees; or lateral position Rationale: * bedrest in position of comfort decreases muscle spasm, reduces stress on structures, and facilitates reduction of disc protrusion c.) instruct in logrolling technique for position change if patient requires Rationale: reduces flexion, twisting, and strain on back, especially when nerve impingement impairs patients ability to move legs d.) limit activity during acute phase as indicated. Intersperse rest periods, shortening rest interval and length as patient improves Rationale: decreases forces of gravity and motion, which can relieve muscle spasms and reduce edema and stress on structures around affected disc e.) provide opportunities to talk/listen to concerns. Rationale: ventilation of worries can help decrease stress factors present in illness/hospitalization. provides opportunity to give information/correct misinformation. f.) provide orthopedic bed or firm mattress. Rationale: provides support and reduces spinal flexion, decreasing spasms. g.) administer medications as indicated: nonsteroidal anti-inflammatory drugs (nsaids), e.g., nabumetone (relafen), ibuprofen (motrin, advil), etodolac (lodine), diflunisal (dolobid), ketoprofen (orudis), meclofenamate (meclomen) Rationale: * suppresses pain and inflammation, decreases edema and pressure on nerve root(s).note: epidural or facet joint injection of anti-inflammatory drugs may be tried if other interventions fail to alleviate pain. mobility, impaired physical May be related to: pain and discomfort, muscle spasms restrictive therapies, e.g., bed rest, traction neuromuscular impairment

Interventions: a.) perform/assist with passive and active ROM exercises. encourage lower leg/ankle exercises. evaluate for edema, erythema of lower extremities, calf pain/tenderness, presence of homans sign Rationale: strengthens abdominal muscles and flexors of spine; promotes good body mechanics b.) provide good skin care; gently massage pressure points after each position change. check skin under brace periodically. Rationale: * stimulates venous circulation/return, decreasing venous stasis and possible thrombus formation. C.) encourage diet high in fiber and adequate fluid intake. Rationale: reduces risk of skin irritation/breakdown d.) assist with activity/progressive ambulation Rationale: * activity depends on individual situation but usually progresses slowly according to tolerance Huntington's Chorea Huntingtons disease (also called Huntingtons chorea) is a rare abnormal hereditary disorder of the CNS. It is characterized by chronic progressive chorea (involuntary purposeless, rapid movements) and mental deterioration that results in dementia. Causes and incidence Chorea, the Greek word meaning dance. It is described as involuntary movements of the body. Is a progressive neurodegenerative genetic disorder that affects muscle coordination. Results in the destruction of certain cells in the brain. Huntingdons disease is inherited as a single faulty gene on chromosome #4 whereby part of the gene is repeated in multiple copies. Its transmitted as an autosomal dominant trait; either sex can transmit and inherit it. Each child of a parent with this disease has a 50% chance of inheriting it. The disease usually strikes people between ages 35 and 55; however, 2% of cases occur in children, and 5% of cases occur as late as age 60. Death usually results 10 to 15 years after onset, from suicide, heart failure, or pneumonia. Genetic

testing is available for persons with a family history of the disease. Complications Weight loss Pneumonia Congestive heart failure Bed sore Risk Factors Hereditary (autosomal dominant gene transmission) Idiopathic Clinical Manifestations Intellectual decline Abnormal movements Restlessness, forgetfulness, clumsiness, frequent falls Problems with speech, coordination and balance Depression, memory loss, emotional lability and impulsiveness Facial grimaces, protrusion of the tongue, jerky movements of the arms and legs Gait disturbances, patient at risk for falls Medical Management Disease management includes rehabilitative therapy, teaching, counseling and professional legal, financial and estate planning advice. It is not curable and is eventually fatal Disturbed thought processes and impaired social interacton Patient comfort and support are the primary considerations. Provide physical support by attending to the patients basic needs, such as hygiene, skin care, bowel and bladder care, and nutrition. Increase this support as mental and physical deterioration make him increasingly immobile. Risk for aspiration related to swallowing difficulty Keep pt. as close to upright as possible whilw feeding. Stabilize pt. head genthly with one hand while feeding. Offer emotional support to the patient and his family. Teach them about the disease, and listen to their concerns and special problems. Keep in mind the patients dysarthria, and allow him extra time to express himself, thereby decreasing frustration. Teach the family to participate in the patients care.

 Stay alert for possible suicide attempts. Control the patients environment to protect him from suicide or other self-inflicted injury. Pad the side rails of the bed, but avoid restraints, which may cause the patient to injure himself with violent, uncontrolled movements. If the patient has difficulty walking, provide a walker to help him maintain his balance. Make sure affected families receive genetic counseling. All affected family members should realize that each of their offspring has a 50% chance of inheriting this disease. Refer people at risk who desire genetic testing to centers specializing in Huntingtons care, where psychosocial support is available. Refer the patient and his family to the appropriate community organizations RESTLESS LEG SYNDROME Restless legs syndrome (RLS) or Willis-Ekbom disease is a neurologic disorder characterized by an irresistible urge to move one's body to stop uncomfortable or odd sensations.It most commonly affects the legs, but can affect the arms, torso, and even phantom limbs. CAUSE Lack of iron TYPES Primary RLS (Idiopathic) Secondary RLS s/sx: Leg discomfort and strong urge to move Pain Nighttime twitching Tx: NONPHARMACOLOGIC TREATMENT relaxation techniques avoiding caffeine, alcohol, and tobacco exercising every day and maintaining a schedule of relaxation and avoiding heavy meals before bed Stretching, shaking legs and other methods of relief Activities that alert the mind like crossword puzzle for symptoms that occur in evening PHARMACEUTICAL Iron supplements Dopamine antagonist (levodopa) Gabapentin enacarbil (horizant) Opioids

Benzodiazepines(Diazepam) Anticonvulsant( Carbamazepine) NSG DIAGNOSIS SLEEP DEPRIVATION RELATED TO LEG DISCOMFORT Determine the presence of physical and psychological stressors Note medical diagnoses that affect sleep Observe physical sign of fatique Promote adequate physical activities during day Instruct in relaxation technique FATIGUE RELATED TO LACK OF SLEEP Assess vital signs Determine presence/degree of sleep disturbance Note recent lifrstyle changes Note daily energy pattern Establish realistic activity goal with client and encourage for ward movement Plan intervention to allow individually adequate rest period.schedule activities for period when client has the most energy Arteriovenous Malformations O Arteriovenous malformations (AVMs) are defects of thecirculatory system that are generally believed to arise during embryonic or fetal development or soon after birth. They are comprised of snarled tangles of arteries and veins. O Arteries carry oxygen-rich blood away from theheart to the body's cells; veins return oxygendepleted blood to the lungs and heart. The presence of an AVM disrupts this vital cyclical process. Although AVMs can develop in many different sites, those located in the brain or spinal cord-the two parts of the central nervous systemcan have especially widespread effects on the body. O They occur in males and females of all racial or ethnic backgrounds at roughly equal rates. O AVMs damage the brain or spinal cord through three basic mechanisms: by reducing the amount of oxygen reaching neurological tissues; by causing bleeding (hemorrhage) into surrounding tissues; and by compressing or displacing parts of the brain or spinal cord. S/sx O Most people with neurological AVMs experience few, if any, significant symptoms, and the malformations tend to be discovered only

O O O O O O O O

O Tx:

incidentally, usually either at autopsy or during treatment for an unrelated disorder. Seizures and headaches are the most generalized symptoms of AVMs, convulsions, or a change in a person's level of consciousness muscle weakness or paralysis in one part of the body; a loss of coordination (ataxia) that can lead to such problems as gait disturbances; apraxia, or difficulties carrying out tasks that require planning; dizziness; visual disturbances such as a loss of part of thevisual field; an inability to control eye movement; papilledema (swelling of a part of the optic nerve known as the optic disk); various problems using or understanding language (aphasia); abnormal sensations such as numbness, tingling, or spontaneous pain (paresthesia or dysesthesia); memory deficits; and mental confusion, hallucinations, or dementia.

Medication can often alleviate general symptoms such as headache, back pain, and seizures caused by AVMs and other vascular lesions. However, the definitive treatment for AVMs is either surgery or focused irradiation therapy. O Today, three surgical options exist for the treatment of AVMs: conventional surgery, endovascular embolization, and radiosurgery. The choice of treatment depends largely on the size and location of an AVM. Conventional surgery- involves entering the brain or spinal cord and removing the central portion of the AVM, including the fistula, while causing as little damage as possible to surrounding neurological structures. This surgery is most appropriate when an AVM is located in a superficial portion of the brain or spinal cord and is relatively small in size. Endovascular embolization & radiosurgery O Endovascular embolization and radiosurgery are less invasive than conventional surgery and offer safer treatment options for some AVMs located deep inside the brain. In endovascular embolization the surgeon guides a catheter though the arterial network until the tip reaches the site of the AVM. O

The surgeon then introduces a substance that will plug the fistula, correcting the abnormal pattern of blood flow. This process is known as embolization because it causes an embolus (a blood clot) to travel through blood vessels, eventually becoming lodged in a vessel and obstructing blood flow. Radiosurgery O Radiosurgery is an even less invasive therapeutic approach. It involves aiming a beam of highly focused radiation directly on the AVM. The high dose of radiation damages the walls of the blood vessels making up the lesion. Over the course of the next several months, the irradiated vessels gradually degenerate and eventually close, leading to the resolution of the AVM. Delirium Acute confusional state Acute brain syndrome is an acute and debilitating decline in attentionfocus, perception, and cognition that produces an altered form of semi-consciousness. It is a systemic syndrome caused by a chemical or disease-process which is disrupting the neurons of the cerebral cortex Causes Delirium is most often caused by physical or mental illness and is usually temporary and reversible. Many disorders cause delirium, including conditions that deprive the brain of oxygen or other substances. Causes include: Alcohol or sedative drug withdrawal Drug abuse Electrolyte or other body chemical disturbances Infections such as urinary tract infections or pneumonia (more likely in people who already have brain damage from stroke or dementia) Poisons Surgery Manifestations Nervous System: Cognitive Impairment Disturbances of Attention Reduced level of Consciousness Disorganized sleep-wake cycle Musculoskeletal System: Increased or decreased psychomotor O

RISK FACTORS Accidental or intentional poisoning Elderly client Recent major surgery Pre existing cognitive dysfunction Multiple drug therapy, especially polypharmacy of dose High doses of hypnotics Dx. CBC sedimentation rate BUN blood alcohol level urinalysis urine drug screen CT scan of the brain and EEG Arterial blood gases ECG Thyroid tests MRI Medications Neuroleptics Haloperidol (Haldol) Adult Moderate symptomatology: 0.5-2mg PO bid/tid A but pyrophenone high-potency antipsychotic. One of most effective antipsychotics for delirium. High-potency antipsychotic medications also cause less sedation than phenothiazines and reduce risks of exacerbating delirium. Risperidone (Risperdal) Adult 0.5-2 mg PO qd or bidA newer antipsychotic with fewer extra pyramidal adverse effects than Haldol. Binds to dopamine D2-receptor with 20times lower affinity than for 5-HT2-receptor. Improves negative symptoms of psychoses and reduces incidence of adverse extra pyramidal effects. Lorazepam (Ativan) Adult 0.5-2 mg PO/IV/IM ;frequent repeat dosing (q2-4h) may be needed Preferable because it is short acting and has no active metabolites. In addition, can be used in both IM and IV forms. When patient needs to base dated for longer than 24 h, this medication is excellent. Commonly used prophylactically to prevent delirium tremens. Prevention Treating the conditions that cause delirium can reduce its risk. In hospitalized patients, avoiding sedatives, staying still (immobilization), and bladder catheters, and using reality orientation programs will reduce the risk of delirium in those at high risk. Hemorrhagic Stroke

Hemorrhagic stroke account for 15% of cerebrovascular disorders are primarily caused by an intracranial or subarachnoid hemorrhage. Are caused by bleeding into the brain tissue, the ventricles, or the subarachnoid space. Primary intracerebral hemorrhage from a spontaneous rupture of small vessels accounts for approximately 805 of hemorrhagic strokes and is primarily caused by uncontrolled hypertension. Secondary intracerebral hemorrhage is associated with ateriovenous malformations, intracranial aneurysm, or certain medications. Intracerebral Hemorrhage An intracerebral hemorrhage, or bleeding into the brain substance, is most common in patients with hypertension and cerebral atherosclerosis because degenerative changes from this disease cause rupture of the vessel. They also may be due to certain types of arterial pathology, brain tumor, and the use of medications (oral anticoagulants, amphetamines, and illicit drugs such as crack and cocaine). Intracranial Aneurysm An intracranial (cerebral) aneurysm is a dilation of the walls of a cerebral artery that develops as a result of weakness in the arterial wall. The cause of aneurysms is unknown, although research is ongoing. An aneurysm may be due to atherosclerosis, resulting in a defect in the vessel wall with subsequent weakness of the wall; a congenital defect of the vessel wall; hypertensive vascular disease; head trauma; or advancing age. Arteriovenous Malformation An AVM is due to an abnormality in embryonal development that leads to a tangle of arteries and veins in the brain without a capillary bed. The absence of a capillary bed leads to dilation of the arteries and veins and eventual rupture. They are commonly a cause of hemorrhage in young people Subarachnoid Hemorrhage A subarachnoid hemorrhage (hemorrhage into the subarachnoid space) may occur as a result of an AVM, intracranial aneurysm, trauma, or hypertension. The most common cause is a leaking aneurysm in the area of the circle of Willis or congenital AVM of the brain. Present with a wide variety of neurologic deficits. Unusually severe headache and often loss of consciousness for a variable period.

s/sx.

There may be pain and rigidity of the back of the neck (nuchal rigidity) and spine due to meningeal irritation. Visual disturbances (visual loss, diplopia, ptosis) occur when aneurysm is adjacent to the oculomotor nerve. Tinnitus, dizziness, and hemiparesis may also occur. Present with a wide variety of neurologic deficits. Unusually severe headache and often loss of consciousness for a variable period. There may be pain and rigidity of the back of the neck (nuchal rigidity) and spine due to meningeal irritation. Visual disturbances (visual loss, diplopia, ptosis) occur when aneurysm is adjacent to the oculomotor nerve. Tinnitus, dizziness, and hemiparesis may also occur.

Fever Headache Severe, frontal, photophobia, n/v Jolt accentuation Meningismus/altered mental status

Dx

CT scanning to determine the size and location of the hematoma as well as the presence or absence of ventricular blood and hydrocephalus. The Hunt-Hess Classification System guides the physician in diagnosing the severity of subarachnoid hemorrhage after an aneurysmal bleed. Prevention Primary prevention of hemorrhagic stroke is the best approach and includes managing hypertension and ameliorating other significant risk factors. Control of hypertension, especially in individuals over 55 years of age, clearly reduces the risk for hemorrhagic stroke. Medical mgt. To allow the brain to recover from the initial insult (bleeding). Prevent or minimize the risk for rebleeding To prevent or treat complication. Management consist of bed rest with sedation to prevent agitation and stress, management of vasospasm, and surgical or medical treatment to prevent rebleeding. Pharmacology- analgesics Meningitis and Encephalitis Meningitis- Inflammation of the meninges Classic triad:

Meningeal signs Kernig sign: one leg with hip flexed, pain in back with extension of knee Brudzinski sign: flexion of legs and thighs when neck is flexed Encephalitis Inflammation of the cerebral cortex Fever, HA, altered mental status Key: early mental status changes More commonly viruses Obtundation/coma Behavioral or speech problems, neurological signs, seizures Meningoencephalitis Difference from meningitis: less likely fever, more likely personality/behavioral changes Causes of Meningitis Bacterial Viral Fungal: cryptococcus Mycobacteria: MTB Parasitic/protozoa: Naegleria fowleri Noninfectious Medications Paraneoplastic Acute Bacterial Meningitis Streptococcus pneumoniae Neisseria meningitidis Listeria monocytogenes Haemophilus influenzae: nearly unheard of since vaccinations Less common: Gram negatives (Klebsiella, E. coli) History of procedure: Staphylococcus Viral Meningitis Aseptic meningitis Spectrum with encephalitis, meningoenchephalitis Enteroviruses HSV VZV Arboviruses (arthropod borne viruses)

West Nile, Eastern Equine, Western Equine, St. Louis, California, Japanese Encephalitis

HIV Rabies virus Adenovirus CMV, EBV Encephalitis Viral HSV Arboviruses VZV, CMV, EBV, HIV, rabies Enteroviruses Bacterial Listeria monocytogenes Tick-borne illnesses RMSF: Rickettsia rickettsii STARI: Borrelia lonestari Lyme: Borrelia burgdorferi Ehrlichiosis: Ehrlichia chaffoensis Meningitis Risk Factors Age (bimodal peak) Prior neurosurgery, alcoholism, malignancy, steroids, HIV, sinusitis, DM Clinical suspicion Triad: fever, nuchal rigidity, altered mental status: only seen in 40% elderly Only 59% of elderly patients with acute bacterial meningitis had fever Most have at least ONE symptom dx. Do not delay antibiotics if suspected! CT prior to LP in patients with focal neurological deficits, seizures, HIV, or elderly MRI: to identify areas of CNS involvement Temporal involvement with HSVirus Basilar meningitis with TB West Nile Virus Season: summer Mosquito transmission (currently infects 43/ 174 different types of North American mosquitoes) Other routes Placenta Lactation Transfusion Organ transplant Disease of the elderly

Higher mortality in elderly Other risk factors not clear (?maybe HTN and DM leading to better virus entry) Rocky Mountain Spotted Fever Rickettsia rickettsii Gm negative intracellular bacteria Endothelial cells: small vessel vasculitis Southeast, summer Dog Tick, Wood Tick 2nd most common tick-borne illness Fever/headache/nausea/rash 80% Rash: blanching maculopapular, palms/soles, spreads centrally, later petechial and purpuric Hyponatremia, thrombocytopenia, inc ALT CSF: inc TNC, inc protein; neg gram stain