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Neurologic Nursing 2


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  • 2. On completion of this chapter, the learner will be able to:1. Describe the special nursing needs of patients with variedneurologic dysfunction.2. Describe the multiple needs of the patient with altered levelof consciousness.3. Use the nursing process as a framework for care of thepatient with altered level of consciousness.4. Identify the early and late clinical manifestations ofincreased intracranial pressure.
  • 3. Continued…5. Use the nursing process as a framework for care of thepatient with increased intracranial pressure.6. Describe the needs of the patient undergoing intracranial ortransphenoidal surgery.7. Use the nursing process as a framework for care of thepatient undergoing intracranial/transphenoidal surgery.8. Identify the various types and causes of seizures.9. Use the nursing process to develop a plan of care for thepatient experiencing seizures.10. Identify the needs of the patient experiencing headaches.
  • 4. • An altered level of consciousness (LOC) is apparent in thepatient who is not oriented, does not follow commands, orneeds persistent stimuli to achieve a state of alertness.• Coma is a clinical state of unconsciousness in which thepatient is unaware of self or the environment for prolongedperiods (days to months or even years).• Akinetic mutism is a state of unresponsiveness to theenvironment in which the patient makes no movement orsound but sometimes opens the eyes.
  • 5. • Persistent vegetative state is a condition in which thepatient is described as wakeful but devoid of consciouscontent, without cognitive or affective mental function.
  • 6. • As the patient’s state of alertness and consciousnessdecreases, there will be changes in the pupillary response,eye opening response, verbal response, and motor response.• Initial changes may be reflected by subtle behavioral changessuch as restlessness or increased anxiety.
  • 7. • It includes an evaluation of mental status, cranial nervefunction, cerebellar function (balance and coordination),reflexes, and motor and sensory function. LOC, a sensitiveindicator of neurologic function, is assessed based on thecriteria in the Glasgow Coma Scale: eye opening, verbalresponse, and motor response.• The patient’s responses are rated on a scale from 3 to 15. Ascore of 3 indicates severe impairment of neurologic function;a score of 15 indicates that the patient is fully responsive
  • 8. • Diagnostic scanning, imaging, tomography (eg, computedtomography, magnetic resonance imaging, positron emissiontomography), and electroencephalography.• Laboratory tests include analysis of blood glucose,electrolytes, serum ammonia, and blood urea nitrogen levels,as well as serum osmolality, calcium level, and partialthromboplastin and prothrombin times.• Other studies may be used to evaluate serum ketones andalcohol, drug levels, and arterial blood gas levels.
  • 9. • Potential complications for the patient with altered LOCinclude respiratory failure, pneumonia, pressure ulcers, andaspiration.
  • 10. • The first priority of treatment for the patient with altered LOCis to obtain and maintain a patent airway.• The circulatory status (blood pressure, heart rate) ismonitored to ensure adequate perfusion to the body andbrain.• An intravenous catheter is inserted to provide access forfluids and intravenous medications.• Nutritional support, using either a feeding tube or agastrostomy tube, is initiated as soon as possible.
  • 11. MAINTAINING THE AIRWAY• Elevating the head of the bed to 30 degrees helps preventaspiration.• Positioning the patient in a lateral or semi prone position willalso help as it permits the jaw and tongue to fall forward, thuspromoting drainage of secretions.• The patient may require suctioning and oral hygiene.• Nursing actions for the mechanically ventilated patientinclude maintaining the patency of the endotracheal tube ortracheostomy, providing frequent oral care, monitoring arterialblood gas measurements, and maintaining ventilator settings.
  • 12. PROTECTING THE PATIENT• For the protection of the patient, padded side rails areprovided and raised at all times.• Protection also encompasses the concept of protecting thepatient’s dignity during altered LOC.• The comatose patient has an increased need for advocacy,and it is the nurse’s responsibility to see that these advocacyneeds are met.
  • 13. MAINTAINING FLUID BALANCE AND MANAGINGNUTRITIONAL NEEDS• Fluid needs are met initially by giving the required fluidsintravenously.• The quantity of fluids administered may be restricted tominimize the possibility of producing cerebral edema.• If the patient does not recover quickly and sufficiently enoughto take adequate fluids and calories by mouth, a feeding tubewill be inserted for the administration of fluids and enteralfeedings.
  • 14. PROVIDING MOUTH CARE• The mouth is inspected for dryness, inflammation, andcrusting.• The unconscious patient requires conscientious oral carebecause there is a risk of parotitis if the mouth is not keptscrupulously clean.• A thin coating of petrolatum on the lips prevents drying,cracking, and encrustations.• If the patient has an endotracheal tube, the tube should bemoved to the opposite side of the mouth daily to preventulceration of the mouth and lips.
  • 15. MAINTAINING SKIN AND JOINT INTEGRITY• Assessment includes a regular schedule of turning to avoidpressure, which can cause breakdown and necrosis of theskin.• Turning also provides kinesthetic (sensation of movement),proprioceptive (awareness of position), and vestibular(equilibrium) stimulation.• After turning, the patient is carefully repositioned to preventischemic necrosis over pressure areas.• Maintaining correct body position is important; equallyimportant is passive exercise of the extremities to preventcontractures.
  • 16. MAINTAINING SKIN AND JOINT INTEGRITY• The use of splints or foam boots aids in the prevention of footdrop and eliminates the pressure of bedding on the toes.• Trochanter rolls supporting the hip joints keep the legs inproper alignment.• The arms should be in abduction, the fingers lightly flexed,and the hands in slight supination.• The heels of the feet should be assessed for pressure areas.• Specialty beds, such as fluidized or low-air-loss beds, may beused to decrease pressure on bony prominences.
  • 17. PRESERVING CORNEAL INTEGRITY• The eyes may be cleansed with cotton balls moistened withsterile normal saline to remove debris and discharge.• If artificial tears are prescribed, they may be instilled every 2hours.• Periocular edema (swelling around the eyes) often occursafter cranial surgery. Cold compresses may be prescribed,and care must be exerted to avoid contact with the cornea.• Eye patches should be used cautiously.
  • 18. ACHIEVING THERMOREGULATION• The environment can be adjusted, depending on the patient’scondition, to promote a normal body temperature.• If body temperature is elevated, a minimum amount ofbedding—a sheet or perhaps only a small drape—is used.• The room may be cooled to 18.3°C. However, if the patient iselderly and does not have an elevated temperature, a warmerenvironment is needed.
  • 19. ACHIEVING THERMOREGULATIONStrategies for reducing fever include:• Removing all bedding over the patient (with the possibleexception of a light sheet or small drape)• Administering repeated doses of acetaminophen asprescribed• Giving a cool sponge bath and allowing an electric fan toblow over the patient to increase surface cooling• Using a hypothermia blanket• Frequent temperature monitoring is indicated.
  • 20. PREVENTING URINARY RETENTION• The bladder is palpated or scanned at intervals to determinewhether urinary retention is present.• If there are signs of urinary retention, initially an indwellingurinary catheter attached to a closed drainage system isinserted.• The patient is observed for fever and cloudy urine. The areaaround the urethral orifice is inspected for drainage.• An intermittent catheterization program may be initiated toensure complete emptying of the bladder at intervals, ifindicated.
  • 21. PREVENTING URINARY RETENTION• An external catheter (condom catheter) for the male patientand absorbent pads for the female patient can be used for theunconscious patient who can urinate spontaneously althoughinvoluntarily.• As soon as consciousness is regained, a bladder-trainingprogram is initiated.• The incontinent patient is monitored frequently for skinirritation and skin breakdown.• Appropriate skin care is implemented to prevent thesecomplications.
  • 22. PROMOTING BOWEL FUNCTION• The abdomen is assessed for distention by listening for bowelsounds and measuring the girth of the abdomen with a tapemeasure.• There is a risk of diarrhea from infection, antibiotics, andhyperosmolar fluids.• Immobility and lack of dietary fiber may cause constipation.• The nurse monitors the number and consistency of bowelmovements and performs a rectal examination for signs offecal impaction.
  • 23. PROMOTING BOWEL FUNCTION• Stool softeners may be prescribed and can be administeredwith tube feedings.• To facilitate bowel emptying, a glycerine suppository may beindicated.• The patient may require an enema every other day to emptythe lower colon.
  • 24. PROVIDING SENSORY STIMULATION• Efforts are made to maintain the sense of daily rhythm bykeeping the usual day and night patterns for activity andsleep.• The nurse touches and talks to the patient and encouragesfamily members and friends to do so.• Communication is extremely important and includes touchingthe patient and spending enough time with him or her tobecome sensitive to his or her needs.• It is also important to avoid making any negative commentsabout the patient’s status or prognosis in the patient’spresence.
  • 25. PROVIDING SENSORY STIMULATION• The nurse orients the patient to time and place at least onceevery 8 hours.• Sounds from the patient’s home and workplace may beintroduced using a tape recorder.• Family members can read to the patient from a favorite bookand may suggest radio and television programs that thepatient previously enjoyed as a means of enriching theenvironment and providing familiar input.• When arousing from coma it is necessary to minimize thestimulation to the patient by limiting background noises.
  • 26. PROVIDING SENSORY STIMULATION• Only one person speak to the patient at a time, giving thepatient a longer period of time to respond, and allowing forfrequent rest or quiet times.• When the patient has regained consciousness, videotapedfamily or social events may assist the patient in recognizingfamily and friends and allow him or her to experience missedevents.
  • 27. MEETING FAMILIES’ NEEDS• The family of the patient with altered LOC may be thrown intoa sudden state of crisis and go through the process of severeanxiety, denial, anger, remorse, grief, and reconciliation.• The nurse can reinforce and clarify information about thepatient’s condition, permit the family to be involved in care,and listen to and encourage ventilation of feelings andconcerns while supporting them in their decision-makingprocess about post hospitalization management andplacement.
  • 28. MEETING FAMILIES’ NEEDS• The term brain death describes irreversible loss of allfunctions of the entire brain, including the brain stem.• When discussing a patient who is brain dead with familymembers, it is important to use the term ―dead‖; the term―brain dead‖ may confuse them.
  • 29. MONITORING AND MANAGINGPOTENTIAL COMPLICATIONS• Vital signs and respiratory function are monitored closely todetect any signs of respiratory failure or distress.• Total blood count and arterial blood gas measurements areassessed.• Chest physiotherapy and suctioning are initiated to preventrespiratory complications.• If pneumonia develops, cultures are obtained to identify theorganism so that appropriate antibiotics can be administered.
  • 30. MONITORING AND MANAGINGPOTENTIAL COMPLICATIONS• The patient should also be monitored for signs and symptomsof deep vein thrombosis.• Prophylaxis such as subcutaneous heparin or low-molecular-weight heparin should be prescribed. Thigh-high elasticcompression stockings or pneumatic compression stockingsshould also be prescribed to reduce the risk for clot formation.• Measures to assess for deep vein thrombosis, such asHomans’ sign, and the nurse should observe for redness andswelling in the lower extremities.
  • 31. MONITORING AND MANAGINGPOTENTIAL COMPLICATIONS• The patient should also be monitored for signs and symptomsof deep vein thrombosis.• Prophylaxis such as subcutaneous heparin or low-molecular-weight heparin should be prescribed. Thigh-high elasticcompression stockings or pneumatic compression stockingsshould also be prescribed to reduce the risk for clot formation.• Measures to assess for deep vein thrombosis, such asHomans’ sign, and the nurse should observe for redness andswelling in the lower extremities.
  • 32. The family of a 55-year-old woman who has beendiagnosed as being in a persistent vegetative state wants towithdraw tube feedings and let her die. The nursing staffexpress concern about removing the feeding tube, relating thatthe patient has wakeful periods and sometimes seems to moveher eyes toward them when they care for her. The family’swishes, however, are honored and the medical teamdiscontinues all tube feedings and intravenous lines and orderscomfort measures only. The patient dies 7 days later.
  • 33. • The rigid cranial vault contains brain tissue (1,400 g), blood(75 mL), and CSF (75 mL). The volume and pressure ofthese three components are usually in a state of equilibriumand produce the ICP.• ICP is usually measured in the lateral ventricles; normal ICPis 10 to 20 mm Hg.• The Monro-Kellie hypothesis states that because of thelimited space for expansion within the skull, an increase inany one of the components causes a change in the volume ofthe others.
  • 34. DECREASED CEREBRAL BLOOD FLOW• In the early stages of cerebral ischemia, the vasomotorcenters are stimulated and the systemic pressure rises tomaintain cerebral blood flow.• A rise in carbon dioxide partial pressure (PaCO2) causescerebral vasodilatation, leading to increased cerebral bloodflow and increased ICP; a fall in PaCO2 has avasoconstrictive effect.• Decreased venous outflow may also increase cerebral bloodvolume, thus raising ICP.
  • 35. CEREBRAL EDEMA• As brain tissue swells within the rigid skull, severalmechanisms attempt to compensate for the increasing ICP.These mechanisms include autoregulation and decreasingthe production and flow of CSF.• Autoregulation refers to the brain’s ability to change thediameter of its blood vessels automatically to maintain aconstant cerebral blood flow during alterations in systemicblood pressure.
  • 36. CEREBRAL RESPONSE TO INCREASED ICP• The brain can maintain a steady perfusion pressure when thearterial systolic blood pressure is 50 to 150 mm Hg and ICP isless than 40 mm Hg.• The cerebral perfusion pressure is calculated by subtractingthe ICP from the mean arterial pressure. The normal cerebralperfusion pressure is 70 to 100 mm Hg.• Patients with a cerebral perfusion pressure less than 50 mmHg experience irreversible neurologic damage.
  • 37. CEREBRAL RESPONSE TO INCREASED ICP• Cushing’s response is seen when there is a rise in thesystolic blood pressure with a widening of the pulse pressureand cardiac slowing.• The bradycardia, hypertension, and bradypnea associatedwith this deterioration are known as Cushing’s triad.• At this point, herniation of the brain stem and occlusion of thecerebral blood flow occur if therapeutic intervention is notinitiated.
  • 38. • Any sudden change in the patient’s condition, such asrestlessness (without apparent cause), confusion, orincreasing drowsiness, has neurologic significance.• As ICP increases, the patient becomes stuporous, reactingonly to loud auditory or painful stimuli.• As neurologic function deteriorates further, the patientbecomes comatose and exhibits abnormal motor responsesin the form of decortication, decerebration, or flaccidity• When the coma is profound, with the pupils dilated and fixedand respirations impaired, death is usually inevitable.
  • 39. • The patient may undergo cerebral angiography, computedtomography (CT) scanning, magnetic resonance imaging(MRI), or positron emission tomography (PET).• Transcranial Doppler studies provide information aboutcerebral blood flow.• The patient with increased ICP may also undergoelectrophysiologic monitoring and evoked potentialmonitoring.• Lumbar puncture is avoided in patients with increased ICPbecause the sudden release of pressure can cause the brainto herniate.
  • 40. • Complications of increased ICP include brain stem herniation,diabetes insipidus, and syndrome of inappropriate antidiuretichormone (SIADH).
  • 41. • Immediate management to relieve increased ICP involvesdecreasing cerebral edema, lowering the volume of CSF, ordecreasing cerebral blood volume while maintaining cerebralperfusion.• These goals are accomplished by administering osmoticdiuretics and corticosteroids, restricting fluids, draining CSF,controlling fever, maintaining systemic blood pressure andoxygenation, and reducing cellular metabolic demands.• Judicious use of hyperventilation is recommended only if theICP is refractory to other measures.
  • 42. MONITORING ICP• An intraventricular catheter (ventriculostomy), a subarachnoidbolt, an epidural or subdural catheter, or a fiberoptictransducer-tipped catheter placed in the subdural space orthe ventricle can be used to monitor ICP.
  • 43. DECREASING CEREBRAL EDEMA• Osmotic diuretics (mannitol) may be given to dehydrate thebrain tissue and reduce cerebral edema.• Corticosteroids (eg, dexamethasone) help reduce theedema surrounding brain tumors when a brain tumor is thecause of increased ICP.• Another method for decreasing cerebral edema is fluidrestriction.
  • 44. MAINTAINING CEREBRAL PERFUSION• Improvements in cardiac output are made using fluidvolume and inotropic agents such as dobutaminehydrochloride.
  • 45. REDUCING CSF AND INTRACRANIAL BLOOD VOLUME• Excessive drainage may result in collapse of the ventricles.• Hyperventilation, which results in vasoconstriction, hasbeen used for many years in patients with increased ICP.• Hyperventilation is indicated in patients whose ICP isunresponsive to conventional therapies, but it should beused judiciously.
  • 46. CONTROLLING FEVER• Strategies to reduce temperature include administration ofantipyretic medications, as prescribed, and use of a coolingblanket.• The patient’s temperature is monitored closely, and thepatient is observed for shivering, which should be avoidedbecause it increases ICP.
  • 47. MAINTAINING OXYGENATION• Arterial blood gases must be monitored to ensure thatsystemic oxygenation remains optimal.• Hemoglobin saturation can also be optimized to provideoxygen more efficiently at the cellular level.
  • 48. REDUCING METABOLIC DEMANDS• Cellular metabolic demands may be reduced through theadministratio of high doses of barbiturates when the patientis unresponsive to conventional treatment.• Another method of reducing cellular metabolic demand andimproving oxygenation is the administration ofpharmacologic paralyzing agents.• Pentobarbital (Nembutal), thiopental (Pentothal), andpropofol (Diprivan) are the most common agents used forhigh-dose barbiturate therapy.
  • 49. • A craniotomy involves opening the skull surgically to gainaccess to intracranial structures. This procedure isperformed to remove a tumor, relieve elevated ICP,evacuate a blood clot, and control hemorrhage.• One of two approaches through the skull is used: (1) abovethe tentorium (supratentorial craniotomy) into thesupratentorial compartment, or (2) below the tentorium intothe infratentorial (posterior fossa) compartment.• A transsphenoidal approach through the mouth and nasalsinuses is used to gain access to the pituitary gland.
  • 50. • Burr holes are made for exploration or diagnosis. They maybe used to determine the presence of cerebral swelling andinjury and the size and position of the ventricles.• They are also a means of evacuating an intracranialhematoma or abscess and for making a bone flap in theskull and allowing access to the ventricles fordecompression, ventriculography, or shunting procedures.• Other cranial procedures include craniectomy (excision ofa portion of the skull) and cranioplasty (repair of a cranialdefect using a plastic or metal plate).
  • 51. • Preoperative diagnostic procedures may include CTscanning to demonstrate the lesion and show the degree ofsurrounding brain edema, the ventricular size, and thedisplacement.• MRI provides information similar to that of the CT scan andexamines the lesion in other planes.• Cerebral angiography may be used to study the tumor’sblood supply or give information about vascular lesions.• Transcranial Doppler flow studies are used to evaluate theblood flow of intracranial blood vessels.
  • 52. • Most patients are placed on an antiseizure medication suchas phenytoin (Dilantin) or a phenytoin metabolite (Cerebyx)before surgery to reduce the risk of postoperative seizures.• Before surgery, corticosteroids such as dexamethasone(Decadron) may be administered to reduce cerebral edema.• Fluids may be restricted.• A hyperosmotic agent (mannitol) and a diuretic agent suchas furosemide (Lasix) may be given intravenously.• The patient may be given antibiotics if there is a chance ofcerebral contamination; diazepam may be prescribedbefore surgery to allay anxiety.
  • 53. • Assessment includes evaluating LOC and responsivenessto stimuli and identifying any neurologic deficits, such asparalysis, visual dysfunction, alterations in personality orspeech, and bladder and bowel disorders.• Distal and proximal motor strength in both upper and lowerextremities is recorded using the 5-point scale.• The patient’s and family’s understanding of and reactions tothe anticipated surgical procedure and its possible sequelaeare assessed, as is the availability of support systems forthe patient and family.
  • 54. • Adequate preparation for surgery, with attention to thepatient’s physical and emotional status, can reduce the riskfor anxiety, fear, and postoperative complications.• If there are motor deficits or weakness or paralysis of thearms or legs, trochanter rolls are applied to the extremitiesand the feet are positioned against a footboard.• A patient who can ambulate is encouraged to do so.• If the patient is aphasic, writing materials or picture andword cards of frequently used items may help improvecommunication.
  • 55. • Preparation of the patient and family includes providinginformation about what to expect during and after surgery.• The surgical site is shaved immediately before surgery sothat any resultant superficial abrasions do not have time tobecome infected.• An indwelling urinary catheter is inserted in the operatingroom to drain the bladder during the administration ofdiuretics and to permit urinary output to be monitored.• The patient may have a central and arterial line placed forfluid administration and monitoring of pressures aftersurgery.
  • 56. REDUCING CEREBRAL EDEMA• Medications to reduce cerebral edema include mannitol,which increases serum osmolality and draws free waterfrom areas of the brain (with an intact blood–brain barrier).• Dexamethasone (Decadron) may be administeredintravenously every 6 hours for 24 to 72 hours; the route isswitched to oral as soon as possible and dosage is taperedover 5 to 7 days.
  • 57. RELIEVING PAIN AND PREVENTING SEIZURES• Acetaminophen is usually prescribed for temperatureexceeding 99.6°F (37.5°C) and for pain.• Codeine, given parenterally, is often sufficient to relieveheadache.• Morphine sulfate may also be used in the management ofpostoperative pain in the craniotomy patient.• Antiseizure medication (phenytoin, diazepam) is prescribedfor patients who have undergone supratentorial craniotomy.
  • 58. MONITORING ICP• The ICP can be assessed using a stopcock attached to thepressure tubing and transducer.• Care is required to ensure that the system is tight at allconnections and that the stopcock is in the proper positionto avoid drainage of CSF; collapse of the ventricles andbrain herniation may result if fluid is removed too rapidly.
  • 59. • Tumors within the sella turcica and small adenomas of thepituitary can be removed through a transsphenoidalapproach: an incision is made beneath the upper lip andentry is then gained successively into the nasal cavity,sphenoidal sinus, and sella turcica.• It avoids many of the risks of craniotomy, and thepostoperative discomfort is similar to that of othertransnasal surgical procedures.• It may also be used for pituitary ablation (removal) inpatients with disseminated breast or prostatic cancer.
  • 60. • Manipulation of the posterior pituitary gland during surgerymay produce transient diabetes insipidus of several days’duration.• It is treated with vasopressin but occasionally persists.• Other complications include CSF leakage, visualdisturbances, postoperative meningitis, and SIADH.
  • 61. • The preoperative workup includes a series of endocrinetests, rhinologic evaluation (to assess the status of thesinuses and nasal cavity), and neuroradiologic studies.• Funduscopic examination and visual field determinationsare performed, because the most serious effect of pituitarytumor is localized pressure on the optic nerve or chiasm.• The nasopharyngeal secretions are cultured because asinus infection is a contraindication to an intracranialprocedure through this approach.• Corticosteroids may be administered before and aftersurgery.
  • 62. • Antibiotics may or may not be administered prophylactically.• Deep breathing is taught before surgery.• The patient is instructed that following the surgery he or shewill need to avoid vigorous coughing, blowing the nose,sucking through a straw, or sneezing, because theseactions may cause a CSF leak.
  • 63. • Management focuses on preventing infection andpromoting healing.• Medications include antimicrobial agents (which arecontinued until the nasal packing inserted at the time ofsurgery is removed), corticosteroids, analgesic agents fordiscomfort, and agents for the control of diabetes insipiduswhen necessary.
  • 64. • Vital signs are measured to monitor hemodynamic, cardiac,and ventilatory status.• The head of the bed is raised to decrease pressure on thesella turcica and to promote normal drainage.• The patient is cautioned against blowing the nose orengaging in any activity that raises ICP, such as bendingover or straining during urination or defecation.• Intake and output are measured as a guide to fluid andelectrolyte replacement. The urine specific gravity ismeasured after each voiding.
  • 65. • Daily weight is monitored.• Fluids are generally given when nausea ceases, and thepatient then progresses to a regular diet.• The nasal packing inserted during surgery is checkedfrequently for blood or CSF drainage.• Oral care is provided every 4 hours or more frequently.• Petrolatum is soothing when applied to the lips.• The packing is removed in 3 to 4 days, and only then canthe area around the nares be cleaned with the prescribedsolution to remove crusted blood and moisten the mucousmembranes.
  • 66. • Home care considerations include advising the patient touse a room humidifier to keep the mucous membranesmoist and to soothe irritation.• The head of the bed is elevated for at least 2 weeks aftersurgery.
  • 67. • Seizures are episodes of abnormal motor, sensory,autonomic, or psychic activity (or a combination of these)resulting from sudden excessive discharge from cerebralneurons.• The international classification of seizures differentiatesbetween two main types: partial seizures that begin in onepart of the brain, and generalized seizures that involveelectrical discharges in the whole brain.• Most seizures are sudden and transient.
  • 68. PARTIAL SEIZURESSimple partial seizures• With motor symptoms• With special sensory or somatosensory symptoms• With autonomic symptoms• Compound forms
  • 69. PARTIAL SEIZURES (SEIZURES BEGINNING LOCALLY)Complex partial seizures• With impairment of consciousness only• With cognitive symptoms• With affective symptoms• With psychosensory symptoms• With psychomotor symptoms (automatisms)• Compound formsPartial seizures secondarily generalized
  • 70. GENERALIZED SEIZURES•Tonic-clonic seizures•Tonic seizures•Clonic seizures•Absence seizures•Atonic seizures•Myoclonic seizures (bilaterally massive epileptic)
  • 71. • The specific causes of seizures are varied and can becategorized as idiopathic (genetic, developmental defects)and acquired.• Among the causes of acquired seizures are hypoxemia ofany cause, including vascular insufficiency, fever(childhood), head injury, hypertension, central nervoussystem infections, metabolic and toxic conditions (eg, renalfailure, hyponatremia, hypocalcemia, hypoglycemia,pesticides), brain tumor, drug and alcohol withdrawal, andallergies.• Cerebrovascular disease is the leading cause of seizures inthe elderly.
  • 72. • A major responsibility of the nurse is to observe and recordthe sequence of symptoms.• The nature of the seizure usually indicates the type oftreatment that is required.Before andduring a seizure, the following are assessed anddocumented:• The circumstances before the seizure (visual, auditory, orolfactory stimuli, tactile stimuli, emotional or psychologicaldisturbances, sleep, hyperventilation)• The occurrence of an aura (visual, auditory, or olfactory)
  • 73. • The first thing the patient does in a seizure—where themovements or the stiffness starts, conjugate gaze position,and the position of the head at the beginning of the seizure.• The type of movements in the part of the body involved• The areas of the body involved.• The size of both pupils. Are the eyes open? Did the eyes orhead turn to one side?• The presence or absence of automatisms (involuntarymotor activity, such as lip smacking or repeated swallowing)• Incontinence of urine or stool
  • 74. • Duration of each phase of the seizure• Unconsciousness, if present, and its duration• Any obvious paralysis or weakness of arms or legs after theseizure• Inability to speak after the seizure• Movements at the end of the seizure• Whether or not the patient sleeps afterward• Cognitive status (confused or not confused) after theseizure
  • 75. • In addition to providing data about the seizure, nursing careis directed at preventing injury and supporting the patient.• This includes supporting the patient not only physically butalso psychologically.• Consequences such as distress, embarrassment, fatigue,and depression can be devastating to the patient.
  • 76. • After a patient has a seizure, the nurse’s role is todocument the events leading to and occurring during theseizure and to prevent complications (eg, aspiration, injury).• To prevent complications, the patient is placed in the side-lying position to facilitate drainage of oral secretions and issuctioned, if needed, to maintain a patent airway andprevent aspiration.• Seizure precautions are maintained, including havingavailable fully functioning suction equipment with a suctioncatheter and oral airway.
  • 77. • The bed is placed in a low position with side rails up andpadded if necessary to prevent patient injury.• The patient may be drowsy and may wish to sleep after theseizure; he or she may not remember events leading up tothe seizure and for a short time thereafter.
  • 78. • Epilepsy is a group of syndromes characterized byrecurring seizures.• Epileptic syndromes are classified by specific patterns ofclinical features, including age of onset, family history, andseizure type.• Epilepsy can be primary (idiopathic) or secondary, when thecause is known and the epilepsy is a symptom of anotherunderlying condition such as a brain tumor.
  • 79. • In simple partial seizures, only a finger or hand may shake,or the mouth may jerk uncontrollably. The person may talkunintelligibly, may be dizzy, and may experience unusual orunpleasant sights, sounds, odors, or tastes, but without lossof consciousness.• In complex partial seizures, the person either remainsmotionless or moves automatically but inappropriately fortime and place, or may experience excessive emotions offear, anger, elation, or irritability. Whatever themanifestations, the person does not remember the episodewhen it is over.
  • 80. • Generalized seizures, previously referred to as grand malseizures, involve both hemispheres of the brain, causingboth sides of the body to react.• There may be intense rigidity of the entire body followed byalternating muscle relaxation and contraction (generalizedtonic–clonic contraction).• The simultaneous contractions of the diaphragm and chestmuscles may produce a characteristic epileptic cry.• The tongue is often chewed, and the patient is incontinentof urine and stool.
  • 81. • After 1 or 2 minutes, the convulsive movements begin tosubside; the patient relaxes and lies in deep coma,breathing noisily.• The respirations at this point are chiefly abdominal. In thepostictal state, the patient is often confused and hard toarouse and may sleep for hours.• Many patients complain of headache, sore muscles,fatigue, and depression.
  • 82. • The diagnostic assessment is aimed at determining thetype of seizures, their frequency and severity, and thefactors that precipitate them.• A developmental history is taken, including events ofpregnancy and childbirth, to seek evidence of preexistinginjury.• The patient is also questioned about illnesses or headinjuries that may have affected the brain.• MRI is used to detect lesions in the brain, focalabnormalities, cerebrovascular abnormalities, and cerebraldegenerative changes.
  • 83. • The electroencephalogram (EEG) furnishes diagnosticevidence in a substantial proportion of patients withepilepsy and aids in classifying the type of seizure.• Telemetry and computerized equipment are used to monitorelectrical brain activity while patients pursue their normalactivities and to store the readings on computer tapes foranalysis.• Video recording of seizures taken simultaneously with EEGtelemetry is useful in determining the type of seizure as wellas its duration and magnitude.
  • 84. • Single photon emission computed tomography (SPECT) isan additional tool sometimes used in the diagnostic workup.• It is useful for identifying the epileptogenic zone so that thearea in the brain giving rise to seizures can be removedsurgically.
  • 85. • Side effects of antiseizure agents may be divided into threegroups: (1) idiosyncratic or allergic disorders, which presentprimarily as skin reactions; (2) acute toxicity, which mayoccur when the medication is initially prescribed; or (3)chronic toxicity, which occurs late in the course of therapy.• Gingival hyperplasia (swollen and tender gums) can beassociated with long-term use of phenytoin (Dilantin).• Periodic physical and dental examinations and laboratorytests are performed for patients receiving medicationsknown to have hematopoietic, genitourinary, or hepaticeffects.
  • 86. • Surgery is indicated for patients whose epilepsy resultsfrom intracranial tumors, abscess, cysts, or vascularanomalies.• Neurosurgery has been aided by several advances,including microsurgical techniques, depth EEGs, improvedillumination and hemostasis, and the introduction ofneuroleptanalgesic agents (droperidol and fentanyl).• A generator may be implanted under the clavicle. Thedevice is connected to the vagus nerve in the cervical area,where it delivers electrical signals to the brain to control andreduce seizure activity.
  • 87. • Status epilepticus is a series of generalized seizures thatoccur without full recovery of consciousness betweenattacks.• Vigorous muscular contractions impose a heavy metabolicdemand and can interfere with respirations.• Repeated episodes of cerebral anoxia and edema may leadto irreversible and fatal brain damage.• Factors that precipitate status epilepticus includewithdrawal of antiseizure medication, fever, and concurrentinfection.
  • 88. • The goals of treatment are to stop the seizures as quicklyas possible, to ensure adequate cerebral oxygenation, andto maintain the patient in a seizure-free state.• An airway and adequate oxygenation are established.• If the patient remains unconscious and unresponsive, acuffed endotracheal tube is inserted.• Intravenous diazepam (Valium), lorazepam (Ativan), orfosphenytoin (Cerebyx) is given slowly in an attempt to haltseizures immediately.• Other medications (phenytoin, phenobarbital) are givenlater to maintain a seizure-free state.
  • 89. • An intravenous line is established, and blood samples areobtained to monitor serum electrolytes, glucose, andphenytoin levels.• EEG monitoring may be useful in determining the nature ofthe seizure activity.• Vital signs and neurologic signs are monitored on acontinuing basis.• An intravenous infusion of dextrose is given if the seizure isdue to hypoglycemia.• If initial treatment is unsuccessful, general anesthesia witha short-acting barbiturate may be used.
  • 90. • The serum concentration of the antiseizure medication ismeasured because a low level suggests that the patientwas not taking the medication or that the dosage was toolow. Cardiac involvement or respiratory depression may belife-threatening. There is also the potential for postictalcerebral edema.
  • 91. • The nurse initiates ongoing assessment and monitoring ofrespiratory and cardiac function because of the risk fordelayed depression of respiration and blood pressuresecondary to administration of antiseizure medications andsedatives to halt the seizures.• Nursing assessment also includes monitoring anddocumenting the seizure activity and the patient’sresponsiveness.• The patient is turned to a side-lying position if possible toassist in draining pharyngeal secretions.
  • 92. • Suction equipment must be available because of the risk foraspiration.• The intravenous line is closely monitored because it maybecome dislodged during seizures.• A person who has received long-term antiseizure therapyhas a significant risk for fractures resulting from bonedisease (osteoporosis, osteomalacia, andhyperparathyroidism), a side effect of therapy.• The patient having seizures can inadvertently injure nearbypeople, so nurses should protect themselves.
  • 93. • Headache is actually a symptom rather than a diseaseentity; it may indicate organic disease (neurologic or otherdisease), a stress response, vasodilation (migraine),skeletal muscle tension (tension headache), or acombination of factors.• A primary headache is one for which no organic cause canbe identified.• These types of headache include migraine, tension-type,and cluster headaches.• Cranial arteritis is another common cause of headache.
  • 94. • Migraine is a symptom complex characterized by periodicand recurrent attacks of severe headache.• The cause of migraine has not been clearly demonstrated,but it is primarily a vascular disturbance that occurs morecommonly in women and has a strong familial tendency.• The typical time of onset is puberty, and the incidence ishighest in adults 20 to 35 years of age.• There are seven subtypes of migraine, including migrainewith and without aura.• Most patients have migraine without an aura.
  • 95. • Tension headaches tend to be more chronic than severeand are probably the most common type of headache.• Cluster headaches are a severe form of vascular headache.They are seen five times more frequently in men thanwomen.• Inflammation of the cranial arteries is characterized by asevere headache localized in the region of the temporalarteries.• Cranial arteritis is a cause of headache in the olderpopulation, reaching its greatest incidence in those olderthan 70 years of age.
  • 96. • A secondary headache is a symptom associated with anorganic cause, such as a brain tumor or an aneurysm.• Serious disorders related to headache include brain tumors,subarachnoid hemorrhage, stroke, severe hypertension,meningitis, and head injuries.
  • 97. • The diagnostic evaluation includes a detailed history, aphysical assessment of the head and neck, and a completeneurologic examination.• The health history focuses on assessing the headacheitself, with emphasis on the factors that precipitate orprovoke it.• Patients are asked to describe headaches in their ownwords.• The medication history can provide insight into the patient’soverall health status.
  • 98. • Antihypertensive agents, diuretic medications, anti-inflammatory agents, and monoamine oxidase inhibitorscan provoke headaches.• Emotional factors can play a role in precipitatingheadaches.• Stress is thought to be a major initiating factor in migraineheadaches; therefore, sleep patterns, level of stress,recreational interests,
  • 99. • Antihypertensive agents, diuretic medications, anti-inflammatory agents, and monoamine oxidase inhibitorscan provoke headaches.• Emotional factors can play a role in precipitatingheadaches.• Stress is thought to be a major initiating factor in migraineheadaches; therefore, sleep patterns, level of stress,recreational interests.• The age at onset of headache; the headache’s frequency,location, and duration; the type of pain; factors that relieveand precipitate the event; and associated symptoms arereviewed.
  • 100. • In patients who demonstrate abnormalities on theneurologic examination, CT, cerebral angiography, or MRImay be used to detect underlying causes, such as tumor oraneurysm.• Electromyography (EMG) may reveal a sustainedcontraction of the neck, scalp, or facial muscles.• Laboratory tests may include complete blood count,erythrocyte sedimentation rate, electrolytes, glucose,creatinine, and thyroid hormone levels.
  • 101. The migraine with aura can be divided into four phases:Prodrome• The prodrome phase is experienced by 60% of patientswith symptoms that occur hours to days before a migraineheadache.• Symptoms include depression, irritability, feeling cold, foodcravings, anorexia, change in activity level, increasedurination, diarrhea, or constipation.• Patients usually experience the same prodrome with eachmigraine headache.
  • 102. Aura Phase• Aura occurs in up to 31% of patients who have migraines.• The aura usually lasts less than an hour and may provideenough time for the patient to take the prescribedmedication to avert a full-blown attack.• Visual disturbances (ie, light flashes and bright spots) arecommon and may be hemianopic (affecting only half of thevisual field).• Other symptoms that may follow include numbness andtingling of the lips, face, or hands; mild confusion; slightweakness of an extremity; drowsiness; and dizziness.
  • 103. Headache Phase• As vasodilation and a decline in serotonin levels occur, athrobbing headache (unilateral in 60% of patients)intensifies over several hours.• This headache is severe and incapacitating and is oftenassociated with photophobia, nausea, and vomiting. Itsduration varies, ranging from 4 to 72 hours.
  • 104. Recovery Phase• In the recovery phase (termination and postdrome), the paingradually subsides.• Muscle contraction in the neck and scalp is common, withassociated muscle ache and localized tenderness,exhaustion, and mood changes.• Any physical exertion exacerbates the headache pain.• During this post headache phase, patients may sleep forextended periods.
  • 105. • The tension headache is characterized by a steady,constant feeling of pressure that usually begins in theforehead, temple, or back of the neck.• It is often bandlike or may be described as ―a weight on topof my head.‖• Cluster headaches are unilateral and come in clusters ofone to eight daily, with excruciating pain localized to the eyeand orbit and radiating to the facial and temporal regions.• The pain is accompanied by watering of the eye and nasalcongestion. Each attack lasts 30 to 90 minutes and mayhave a crescendo–decrescendo pattern.
  • 106. • Preventive medical management of migraine involves thedaily use of one or more agents that are thought to blockthe physiologic events leading to an attack.• Two beta-blocking agents, propranolol (Inderal) andmetoprolol (Lopressor), inhibit the action of betareceptorscells in the heart and brain that control the dilation of bloodvessels.• Other medications that are prescribed for migraineprevention include amitriptyline hydrochloride (Elavil),divalproex (Valproate), flunarizine, and several serotoninantagonists.
  • 107. • Calcium antagonists (verapamil HCl) are widely used butmay require several weeks at a therapeutic dosage beforeimprovement is noted.• Calcium-channel blockers are not as effective asbetablockers for prevention but may be more appropriatefor some patients, such as those with bradycardia, diabetesmellitus, or asthma.• Alcohol, nitrites, vasodilators, and histamines mayprecipitate cluster headaches.
  • 108. • Prophylactic medication therapy may include beta-blockers,ergotamine tartrate (occasionally), lithium, naproxen(Naprosyn), and methysergide (Sansert); such therapy iseffective in 20% to 40% of cases.
  • 109. • Therapy for migraine headache is divided into abortive(symptomatic) and preventive approaches.• The abortive approach, best employed in patients whosuffer less frequent attacks, is aimed at relieving or limitinga headache at the onset or while it is in progress.• The preventive approach is used in patients whoexperience more frequent attacks at regular or predictableintervals and may have medical conditions that preclude theuse of abortive therapies.
  • 110. • The triptans, serotonin receptor agonists, are the mostspecific antimigraine agents available.• These agents cause vasoconstriction, reduce inflammation,and may reduce pain transmission.• The five triptans in routine clinical use include sumatriptan• (Imitrex), naratriptan (Amerge), rizatriptan (Maxalt),zolmitriptan (Zomig), and almotriptan.• Ergotamine preparations (taken orally, sublingually,subcutaneously, intramuscularly, by rectum, or byinhalation) may be effective in aborting the headache iftaken early in the migraine process.
  • 111. • Cafergot, a combination of ergotamine and caffeine, canarrest or reduce the severity of the headache if taken at thefirst sign of an attack.• The medical management of an acute attack of clusterheadaches may include 100% oxygen by face mask for 15minutes, ergotamine tartrate, sumatriptan, steroids, or apercutaneous sphenopalatine ganglion blockade.• The medical management of cranial arteritis consists ofearly administration of a corticosteroid to prevent thepossibility of loss of vision due to vascular occlusion orrupture of the involved artery.
  • 112. RELIEVING PAIN• Nursing care is directed toward treatment of the acuteepisode.• Nursing care during a fully developed attack includescomfort measures such as a quiet, dark environment andelevation of the head of the bed to 30 degrees.• Symptomatic treatment such as antiemetics may beindicated.• Symptomatic pain relief for tension headache may beobtained by application of local heat or massage.
  • 113. • Additional strategies may include the use of analgesicagents, antidepressant medications, and muscle relaxants.• Regular sleep, meals, exercise, avoidance of peaks andtroughs of relaxation, and avoidance of dietary triggers maybe helpful in avoiding headaches.• Stress reduction techniques, such as biofeedback, exerciseprograms, and meditation, are examples ofnonpharmacologic therapies that may prove helpful.