neurological disorders


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  • In any case suspected of meningitis based on the clinical signs, a lumbar puncture is essential. Sometimes parents are afraid of the procedure and fear it is harmful to the child. It should be emphasized to them that treatment is highly dependent on CSF results. A lumbar puncture may be postponed or withheld in the following situations: presence of significant cardiac or respiratory distress and shock, sign of increased intracranial pressure, infection in the area that the spinal needle will traverse to obtain CSF, and hematologic problems such as thrombocytopenia and coagulation defects.
  • The following are the CSF findings that will make you confirm the diagnosis of meningitis: the CSF pressure may be elevated, there is leukocytosis with predominance of PMNs, the glucose is low, the CSF blood to glucose ratio is <0.40, and the protein is elevated. The stained smears of CSF may be (+) for bacteria. Culture of CSF should be done whenever it is available, but a negative culture does not rule out meningitis.
  • neurological disorders

    2. 2. CRANIOCEREBRAL TRAUMA (HEAD INJURIES) <ul><li>Defined as any injury to the scalp, skull/cranium, or brain. </li></ul><ul><li>Motor vehicle accidents are most common cause </li></ul><ul><li>Other causes: </li></ul><ul><ul><li>Gunshot </li></ul></ul><ul><ul><li>Hacking </li></ul></ul><ul><ul><li>Falls </li></ul></ul><ul><ul><li>accidents </li></ul></ul>
    3. 3. <ul><li>3 mechanisms that contribute to head trauma: </li></ul><ul><li>Acceleration </li></ul><ul><ul><li>Occurs when head is struck by a moving object and set in motion </li></ul></ul><ul><li>Deceleration </li></ul><ul><ul><li>Occurs when moving head strikes a solid, immobile object. </li></ul></ul><ul><li>Deformation </li></ul><ul><ul><li>Injuries in which the force results in deformation and disruption of the integrity of the impacted body part (skull fracture) </li></ul></ul>CRANIOCEREBRAL TRAUMA (HEAD INJURIES)
    4. 4. <ul><li>By description of injury </li></ul><ul><ul><li>Blunt trauma </li></ul></ul><ul><ul><ul><li>Results from acceleration-deceleration injuries </li></ul></ul></ul><ul><ul><li>Penetrating injuries </li></ul></ul><ul><ul><ul><li>Injuries made by foreign bodies (knives, bullets) or those made by bone fragments from skull fracture </li></ul></ul></ul><ul><ul><li>High velocity objects </li></ul></ul><ul><ul><ul><li>As in bullets produce shock waves in the skull and brain. The shock waves may significantly damage brain structures beyond those in the object’s path. </li></ul></ul></ul><ul><ul><li>Coup injury </li></ul></ul><ul><ul><ul><li>Occurs immediately at the point of impact. The same blow may cause injury on the opposite side of the brain </li></ul></ul></ul>CRANIOCEREBRAL TRAUMA (HEAD INJURIES)
    5. 5. <ul><li>According to Structures Damaged </li></ul><ul><li>Primary head injury </li></ul><ul><ul><li>Refers to impact damage, the severity of which is estimated by initial s/sx. </li></ul></ul><ul><ul><li>Includes injuries to the scalp, skull, or brain or all of these. </li></ul></ul>CRANIOCEREBRAL TRAUMA (HEAD INJURIES)
    6. 6. <ul><li>a. Scalp Injuries – include lacerations, hematomas and contusions or abrasions </li></ul><ul><li>Immediate interventions: </li></ul><ul><li>Do not attempt to remove foreign or any penetrating objects from the wound </li></ul><ul><li>Cover head wounds and apply pressure to bleeding scalp. </li></ul>
    7. 7. <ul><li>b. Skull Injuries – often caused by a force sufficient to cause both fracture and brain injury </li></ul><ul><li>3 Types of Skull Fractures: </li></ul><ul><ul><li>Linear skull fracture </li></ul></ul><ul><ul><ul><li>appears as thin lines on X-rays and do not require treatment. </li></ul></ul></ul><ul><ul><li>Depressed skull fracture </li></ul></ul><ul><ul><ul><li>may be palpated and seen on x-ray. It results when the bone is forced below the line of normal contour from impact with moving object, which may caused brain abrasion or laceration. </li></ul></ul></ul><ul><ul><li>Basilar skull fracture </li></ul></ul><ul><ul><ul><li>occurs in bones over the base of the frontal and temporal lobes. </li></ul></ul></ul>
    8. 8. c. Traumatic brain injury <ul><li>1. CONCUSSION </li></ul><ul><li>Involves jarring of head without tissue injury </li></ul><ul><li>Temporary loss of neurologic function lasting fore a few minutes to hours </li></ul><ul><li>Is a head trauma producing brief loss of consciousness (5 min) followed by confusion and/or memory loss (amnesia), may also experience dizziness and nausea and vomiting. </li></ul>
    9. 10. Traumatic brain injury <ul><li>2. CONTUSION </li></ul><ul><li>Involves structural damage </li></ul><ul><li>Is a damage to the brain substance itself, causing multiple areas of petecheal and punctuate hemorrhage and bruised areas. </li></ul><ul><li>The patient becomes unconscious for hours </li></ul>
    10. 11. <ul><ul><ul><li>TYPES OF CEREBRAL CONTUSION: </li></ul></ul></ul><ul><ul><ul><ul><li>Temporal Lobe Contusion </li></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Person is agitated, confused but remains alert </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><li>Frontal Lobe Contusion </li></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Hemiparesis inn an alert head-injured client </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><li>Frontal-Temporal Contusion </li></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Aphasic head-injured person </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><li>Brain Stem Contusion </li></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Renders a person immediately unresponsive or partially comatose </li></ul></ul></ul></ul></ul>
    11. 13. Traumatic brain injury <ul><li>3. Diffuse Axonal injury </li></ul><ul><li>Involves widespread damage to the neurons </li></ul><ul><li>Patient has decerebrate and decorticate posture </li></ul>
    12. 14. Traumatic brain injury <ul><li>4. Intracranial hemorrhage </li></ul><ul><li>Epidural Hematoma- blood collects in the epidural space between skull and dura mater. Usually due to laceration of the middle meningeal artery </li></ul><ul><li>Symptoms develop rapidly </li></ul>
    13. 16. Traumatic brain injury <ul><li>4. Intracranial hemorrhage </li></ul><ul><li>Subdural hematoma- a collection of blood between the dura and the arachnoid mater caused by trauma. This is usually due to tear of dural sinuses or dural venous vessels </li></ul><ul><li>Symptoms usually develop slowly </li></ul>
    14. 18. Traumatic brain injury <ul><li>4. Intracranial hemorrhage </li></ul><ul><li>Intracerebral Hemorrhage and hematoma- bleeding into the substance of the brain resulting from trauma, hypertensive rupture of aneurysm, coagulopahties, vascular abnormalities </li></ul><ul><li>Symptoms develop insidiously, beginning with severe headache and neurologic deficits </li></ul>
    15. 20. Traumatic brain injury <ul><li>MANIFESTATIONS </li></ul><ul><li>1. Altered LOC </li></ul><ul><li>2. CSF otorrhea </li></ul><ul><li>3. CSF rhinorrhea </li></ul><ul><li>4. Racoon eyes and battle sign </li></ul><ul><ul><li>HALO SIGN- blood stain surrounded by a yellowish stain </li></ul></ul><ul><ul><li>Periorbital ecchymosis (bruise around the eye) </li></ul></ul>
    16. 21. Traumatic brain injury <ul><li>NURSING MANAGEMENT </li></ul><ul><li>1. Monitor for declining LOC- use of Glasgow </li></ul><ul><li>2. Maintain patent airway </li></ul><ul><li>Elevate bed, suction prn, monitor ABG </li></ul>
    17. 22. Traumatic brain injury <ul><li>NURSING MANAGEMENT </li></ul><ul><li>3. Monitor F and E balance </li></ul><ul><li>Daily weights </li></ul><ul><li>IVF therapy </li></ul><ul><li>Monitor possible development of DI and SIADH </li></ul>
    18. 23. Traumatic brain injury <ul><li>4. Provide adequate nutrition </li></ul><ul><li>5. Prevent injury </li></ul><ul><li>Use padded side rails </li></ul><ul><li>Minimize environmental stimuli </li></ul><ul><li>Assess bladder </li></ul><ul><li>Consider the use of intermittent catheter </li></ul>
    19. 24. Traumatic brain injury <ul><li>6. Maintain skin integrity </li></ul><ul><li>Prolonged immobility will likely cause skin breakdown </li></ul><ul><li>Turn patient every 2 hours </li></ul><ul><li>Provide skin care every 4 hours </li></ul><ul><li>Avoid friction and shear forces </li></ul>
    20. 25. Traumatic brain injury <ul><li>7. Monitor potential complications </li></ul><ul><li>Increased ICP </li></ul><ul><li>Post-traumatic seizures </li></ul><ul><li>Impaired ventilation </li></ul>
    21. 26. Increased Intracranial Pressure
    22. 27. Increased Intracranial pressure <ul><li>Intracranial pressure more than 15 mmHg </li></ul><ul><li>Brunner= Normal intracranial pressure 10-20 mmHg </li></ul><ul><li>Black = Normal ICP 5-15 mmHg </li></ul><ul><li>Causes: </li></ul><ul><li>Head injury </li></ul><ul><li>Stroke </li></ul><ul><li>Inflammatory lesions </li></ul><ul><li>Brain tumor </li></ul><ul><li>Surgical complications </li></ul>
    23. 28. Increased Intracranial pressure <ul><li>Pathophysiology </li></ul><ul><li>The cranium only contains the brain substance, the CSF and the blood/blood vessels </li></ul><ul><li>MONRO-KELLIE hypothesis- an increase in any one of the components causes a change in the volume of the other </li></ul><ul><li>Any increase or alteration in these structures will cause increased ICP </li></ul>
    24. 29. Increased Intracranial pressure <ul><li>Pathophysiology </li></ul><ul><li>Compensatory mechanisms: </li></ul><ul><li>1. Increased CSF absorption </li></ul><ul><li>2. Blood shunting </li></ul><ul><li>3. Decreased CSF production </li></ul>
    25. 30. Increased Intracranial pressure <ul><li>Pathophysiology </li></ul><ul><li>Decompensatory mechanisms: </li></ul><ul><li>1. Decreased cerebral perfusion </li></ul><ul><li>2. Decreased PO2 leading to brain hypoxia </li></ul><ul><li>3. Cerebral edema </li></ul><ul><li>4. Brain herniation </li></ul>
    26. 31. Decreased cerebral blood flow <ul><li>Vasomotor reflexes are stimulated initially  slow bounding pulses </li></ul><ul><li>Increased concentration of carbon dioxide will cause VASODILATION  increased flow  increased ICP </li></ul>
    27. 32. Cerebral Edema <ul><li>Abnormal accumulation of fluid in the intracellular space, extracellular space or both. </li></ul>
    28. 33. Herniation <ul><li>Results from an excessive increase in ICP when the pressure builds up and the brain tissue presses down on the brain stem </li></ul>
    29. 34. Cerebral response to increased ICP <ul><li>Steady perfusion up to 40 mmHg </li></ul><ul><li>Cushing’s response </li></ul><ul><ul><li>Vasomotor center triggers rise in BP to increase ICP </li></ul></ul><ul><ul><li>Sympathetic response is increased BP but the heart rate is SLOW </li></ul></ul><ul><ul><li>Respiration becomes SLOW </li></ul></ul>
    30. 35. Increased Intracranial pressure <ul><li>CLINICAL MANIFESTATIONS </li></ul><ul><li>Early manifestations : </li></ul><ul><li>Changes in the LOC- usually the earliest </li></ul><ul><li>Pupillary changes- fixed, slowed response </li></ul><ul><li>Headache </li></ul><ul><li>vomiting </li></ul>
    31. 36. Increased Intracranial pressure <ul><li>CLINICAL MANIFESTATIONS </li></ul><ul><li>late manifestations : </li></ul><ul><li>Cushing reflex- systolic hypertension , bradycardia and wide pulse pressure </li></ul><ul><li>bradypnea </li></ul><ul><li>Hyperthermia </li></ul><ul><li>Abnormal posturing </li></ul>
    32. 37. Increased Intracranial pressure <ul><li>Nursing interventions: </li></ul><ul><li>Maintain patent airway </li></ul><ul><li>1. Elevate the head of the bed 15-30 degrees- to promote venous drainage </li></ul><ul><li>2. assists in administering 100% oxygen or controlled hyperventilation- to reduce the CO2 blood levels  constricts blood vessels  reduces edema </li></ul>
    33. 38. Increased Intracranial pressure <ul><li>Nursing interventions </li></ul><ul><li>3. Administer prescribed medications- usually </li></ul><ul><ul><li>Mannitol- to produce negative fluid balance </li></ul></ul><ul><ul><li>corticosteroid- to reduce edema </li></ul></ul><ul><ul><li>anticonvulsants-p to prevent seizures </li></ul></ul>
    34. 39. Increased Intracranial pressure <ul><li>Nursing interventions </li></ul><ul><li>4. Reduce environmental stimuli </li></ul><ul><li>5. Avoid activities that can increase ICP like valsalva, coughing, shivering, and vigorous suctioning </li></ul>
    35. 40. Increased Intracranial pressure <ul><li>Nursing interventions </li></ul><ul><li>6. Keep head on a neutral position. ACOID- extreme flexion, valsalva </li></ul><ul><li>7. monitor for secondary complications </li></ul><ul><ul><li>Diabetes insipidus- output of >200 mL/hr </li></ul></ul><ul><ul><li>SIADH </li></ul></ul>
    36. 41. Assessment of IIP <ul><li>Subjective </li></ul><ul><ul><li>Diplopia </li></ul></ul><ul><ul><li>Personality change </li></ul></ul><ul><ul><li>Thought processes change </li></ul></ul><ul><ul><li>Headache </li></ul></ul><ul><ul><li>Nausea </li></ul></ul>
    37. 42. Assessment of IIP <ul><li>Objective </li></ul><ul><ul><li>Decreasing LOC </li></ul></ul><ul><ul><li>Hyperthermia </li></ul></ul><ul><ul><li>Weakness </li></ul></ul><ul><ul><li>Vomiting </li></ul></ul><ul><ul><li>Seizures </li></ul></ul><ul><ul><li>Papilledema </li></ul></ul><ul><ul><li>Posturing </li></ul></ul><ul><ul><li>Wide pulse pressure </li></ul></ul><ul><ul><li>Bradycardia </li></ul></ul><ul><ul><li>Altered respirations </li></ul></ul><ul><ul><li>Pupils fixed & dilated </li></ul></ul>
    38. 43. Assessment of IIP <ul><li>Diagnostic tests: </li></ul><ul><ul><li>CT scan, MRI </li></ul></ul><ul><ul><li>Close observation </li></ul></ul><ul><ul><li>Craig’s screw </li></ul></ul>
    39. 44. Medical Management of IIP <ul><li>Craniotomy </li></ul><ul><li>Craniectomy </li></ul><ul><li>Tumor removal </li></ul><ul><li>Drainage of ventricles </li></ul><ul><li>Drainage of hematoma </li></ul><ul><li>Intubation </li></ul>
    40. 45. Medical Management of IIP <ul><li>Medications </li></ul><ul><ul><li>Osmotic diuretics - Mannitol </li></ul></ul><ul><ul><li>Corticosteroids - Decadron </li></ul></ul><ul><ul><li>Anticonvulsants - Dilantin </li></ul></ul><ul><li>Internal monitoring </li></ul>
    41. 46. Nursing Care of the Patient With IIP <ul><li>Elevate HOB </li></ul><ul><li>Neck in neutral position </li></ul><ul><li>Avoid flexion hips, waist and neck </li></ul><ul><li>Avoid isometric activity or Valsalva </li></ul><ul><li>Restrict fluids </li></ul><ul><li>Foley </li></ul><ul><li>Suctioning </li></ul><ul><li>O2 </li></ul><ul><li>Hypothermia blanket </li></ul>
    42. 47. Altered LOC
    43. 48. ALTERED LEVEL OF CONSCIOUSNESS <ul><li>Consciousness </li></ul><ul><ul><li>Is a state of being with 2 important aspects: the wakefulness and awareness of self, environment (including place) and time. </li></ul></ul><ul><li>Wakefulness </li></ul><ul><ul><li>ability to maintain an awake state or to be easily aroused from sleep. </li></ul></ul><ul><li>Awareness of self </li></ul><ul><ul><li>the client can identify himself or herself. </li></ul></ul><ul><li>Awareness of place </li></ul><ul><ul><li>client can identify his or her present location and reason for being there. </li></ul></ul><ul><li>Awareness of time </li></ul><ul><ul><li>client knows the date, month and year and can identify common current facts, such as season. </li></ul></ul>
    44. 49. <ul><li>Unconsciousness </li></ul><ul><ul><li>Can be brief, lasting for a few seconds to minutes, or sustained, lasting for an hour or longer. </li></ul></ul><ul><ul><li>To produce unconsciousness: </li></ul></ul><ul><ul><ul><li>Disrupt the ascending reticular activating system, which extends the length of the brain stem and up into the thalamus </li></ul></ul></ul><ul><ul><ul><li>Significantly disrupt the function of both cerebra; hemisphere </li></ul></ul></ul><ul><ul><ul><li>Metabolically depress overall brain function, like drug overdose </li></ul></ul></ul>ALTERED LEVEL OF CONSCIOUSNESS
    45. 50. <ul><li>Coma </li></ul><ul><ul><li>State of sustained unconsciousness in which the patient: </li></ul></ul><ul><ul><ul><li>does not respond to verbal stimuli </li></ul></ul></ul><ul><ul><ul><li>may have varying responses to painful stimuli </li></ul></ul></ul><ul><ul><ul><li>does not move voluntarily </li></ul></ul></ul><ul><ul><ul><li>may have altered respiratory patterns </li></ul></ul></ul><ul><ul><ul><li>may have altered pupillary responses to light </li></ul></ul></ul><ul><ul><ul><li>does not blink. </li></ul></ul></ul><ul><ul><li>The longer the coma lasts, the more likely it is irreversible. </li></ul></ul>ALTERED LEVEL OF CONSCIOUSNESS
    46. 51. <ul><li>Etiology and Risk Factors </li></ul><ul><ul><li>Structural lesions in the brain </li></ul></ul><ul><ul><ul><li>Place pressure on the brain stem or the structures within the posterior cranial fossa (cerebellum, midbrain, pons and medulla) affecting the RAS </li></ul></ul></ul><ul><ul><ul><li>Head trauma, ischemic or hemorrhagic stroke, brain tumor, vehicular accidents, gunshot wounds and falls </li></ul></ul></ul><ul><ul><ul><li>Ischemic stroke = occur with interruption on blood supply to the brain. It can directly affect involved the structure in consciousness or cause swelling of the brain leading to coma </li></ul></ul></ul><ul><ul><ul><li>Hemorrhagic stroke = occur as a consequence of hypertension or from rupture of a vascular anomaly. </li></ul></ul></ul><ul><ul><ul><li>Hemorrhage = cause coma by placing pressure on the brain. </li></ul></ul></ul><ul><ul><ul><li>Tumor = can metastasize and can increase the pressure on the brain leading to coma </li></ul></ul></ul>ALTERED LEVEL OF CONSCIOUSNESS
    47. 52. <ul><ul><li>Etiology and Risk Factors </li></ul></ul><ul><ul><li>Metabolic disorders and diffuse lesions </li></ul></ul><ul><ul><ul><li>Impair wakefulness and awareness by reducing the supply of oxygen and glucose, by allowing waste products to accumulate in the brain, or by altering other cerebral metabolic processes. </li></ul></ul></ul><ul><ul><ul><li>Metabolic means any problem that alters brain metabolism. </li></ul></ul></ul><ul><ul><ul><li>Hypoxia = most common cause of metabolic coma </li></ul></ul></ul><ul><ul><ul><li>Blood loss, high altitudes or carbon monoxide poisoning deprive the brain of oxygen </li></ul></ul></ul>ALTERED LEVEL OF CONSCIOUSNESS
    48. 53. <ul><ul><li>Coma may be induced to treat neurologic disorders </li></ul></ul><ul><ul><ul><li>giving propofol to produce coma to rest the brain and hopefully prevent further brain injury </li></ul></ul></ul><ul><ul><ul><li>therapeutic coma may be induced with extreme brain swelling secondary to brain injury, stroke or metabolic stroke. </li></ul></ul></ul>ALTERED LEVEL OF CONSCIOUSNESS
    49. 54. <ul><ul><li>Pathophysiology </li></ul></ul><ul><ul><ul><li>Consciousness is controlled by RAS and its integrated components. </li></ul></ul></ul><ul><ul><ul><li>RAS begins in the medulla, located in the midbrain, which connects to hypothalamus and thalamus, this in turn connect with the limbic system via hypothalamus. Feedback systems also connect at the brain stem level. </li></ul></ul></ul><ul><ul><ul><li>Reticular formation produces wakefulness </li></ul></ul></ul><ul><ul><ul><li>RAS produces awareness of self and the environment. </li></ul></ul></ul><ul><ul><ul><li>Diffuse cortical connections allow maximum integrations of all conscious-related activities. </li></ul></ul></ul>ALTERED LEVEL OF CONSCIOUSNESS
    50. 55. <ul><ul><li>Pathophysiology </li></ul></ul><ul><ul><ul><li>Disorders affecting any part of the RAS produces coma. </li></ul></ul></ul><ul><ul><ul><li>To produce coma, a disorder must affect both cerebral hemispheres or the brain stem itself. </li></ul></ul></ul><ul><ul><ul><li>Disorders affect these areas in 1 of 3 ways: </li></ul></ul></ul><ul><ul><ul><ul><li>Direct compression or destruction of structures responsible for consciousness. </li></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Tumor, hemorrhage in brain stem, swelling in the cerebral hemispheres </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><li>Decrease in availability of oxygen or glucose = both needed for cerebral metabolism. </li></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Ischemia, hypoxia </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><li>Toxic effects of substance on structures of the RAS </li></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Toxic wastes from liver, kidney, bacterial invasions from meningitis and metabolites from drugs. </li></ul></ul></ul></ul></ul><ul><ul><ul><li>The anatomic location and severity of the problem determine the depth of coma. </li></ul></ul></ul>ALTERED LEVEL OF CONSCIOUSNESS
    51. 56. <ul><ul><li>Clinical manifestations </li></ul></ul><ul><ul><ul><li>Supratentorial lesions </li></ul></ul></ul><ul><ul><ul><ul><li>(located above the dura roofing the cerebellum) </li></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Headache </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Localized sensorimotor deficits </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Seizures </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Manifestation depends on the specific area of the brain affected </li></ul></ul></ul></ul></ul>ALTERED LEVEL OF CONSCIOUSNESS
    52. 57. <ul><ul><li>Clinical manifestations </li></ul></ul><ul><ul><ul><li>Infratentorial area </li></ul></ul></ul><ul><ul><ul><ul><li>(located beneath the dura roofing the cerebellum) </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Cause sudden loss of consciousness </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Unusual respiratory patterns </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Brain stem houses the rhythmic breathing, its function is loss as consciousness decreases, the lower brain stem begins to regulates breathing by responding to changes primarily in the carbon dioxide levels and acid-base and oxygen levels = result to irregular breathing pattern and depth. </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Compression on the cranial nerves leads to cranial nerve deficits. </li></ul></ul></ul></ul>ALTERED LEVEL OF CONSCIOUSNESS
    53. 58. <ul><ul><li>Clinical manifestations </li></ul></ul><ul><ul><ul><ul><li>Metabolic coma </li></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Confusion and stupor = 1st sign </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Motor manifestation is symmetrical </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Tremors </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Asterixis (flapping tremors of the hands </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Myoclonus (single, sudden jerking movement) </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Seizures </li></ul></ul></ul></ul></ul>ALTERED LEVEL OF CONSCIOUSNESS
    54. 59. <ul><ul><li>Diagnostic Test </li></ul></ul><ul><ul><ul><li>CT scan – tumors and bleeding </li></ul></ul></ul><ul><ul><ul><li>MRI </li></ul></ul></ul><ul><ul><ul><li>Lumbar puncture – after CT scan/ MRI is done, when there is no expanding intracranial mass – to prevent risk of herniation caused by sudden changes in CSF pressure. </li></ul></ul></ul><ul><ul><ul><ul><li>CSF cloudy = infection </li></ul></ul></ul></ul><ul><ul><ul><ul><li>CSF bloody = bleeding in ventricles/subarachnoid space </li></ul></ul></ul></ul><ul><ul><ul><li>EEG = can be used to determine if comatose due to continuous seizures. Results are commonly abnormal to patient with coma </li></ul></ul></ul>ALTERED LEVEL OF CONSCIOUSNESS
    55. 60. <ul><ul><li>Diagnostic Test </li></ul></ul><ul><ul><ul><li>Reflexes </li></ul></ul></ul><ul><ul><ul><ul><li>(+) Oculocephalic response (OCR) = doll’s eye reflex </li></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Done in unconscious patient </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Absence of reflex means brain stem function is preserved </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Should not be done for known cervical spine injury </li></ul></ul></ul></ul></ul>ALTERED LEVEL OF CONSCIOUSNESS
    56. 61. <ul><ul><li>Medical Management </li></ul></ul><ul><ul><ul><li>Goal = to preserve brain function and to prevent additional brain injury </li></ul></ul></ul><ul><ul><ul><li>Focus is to maintaining supply of oxygen and glucose to the brain. </li></ul></ul></ul><ul><ul><ul><li>ABC must be maintained. </li></ul></ul></ul><ul><ul><ul><li>Intubation may be needed if respiratory pattern is ineffective </li></ul></ul></ul><ul><ul><ul><li>Ventilation and supplemental oxygen </li></ul></ul></ul><ul><ul><ul><li>Monitoring BP and maintaining systolic pressure between 100 and 160 mmHg, lower/higher cause alteration in cerebral perfusion pressure </li></ul></ul></ul>ALTERED LEVEL OF CONSCIOUSNESS
    57. 62. RUN DOWN on Altered LOC
    58. 63. Altered level of consciousness <ul><li>Etiologic Factors </li></ul><ul><li>Head injury </li></ul><ul><li>Stroke </li></ul><ul><li>Drug overdose </li></ul><ul><li>Alcoholic intoxication </li></ul><ul><li>Diabetic ketoacidosis </li></ul><ul><li>Hepatic failure </li></ul>
    59. 64. Altered LOC – Etiology (Mnemonics) <ul><li>Vowel </li></ul><ul><li>A lcohol </li></ul><ul><li>E pilepsy </li></ul><ul><li>I nsulin </li></ul><ul><li>O piates </li></ul><ul><li>U rates (renal failure) </li></ul><ul><li>TIPPS </li></ul><ul><li>T rauma </li></ul><ul><li>I nfection </li></ul><ul><li>P sych </li></ul><ul><li>P oisons </li></ul><ul><li>S hock </li></ul>
    60. 65. Altered level of consciousness <ul><li>Patient is not oriented </li></ul><ul><li>Patient does not follow command </li></ul><ul><li>Patient needs persistent stimuli to be awake </li></ul><ul><li>COMA= clinical state of unconsciousness where patient is NOT aware of self and environment </li></ul>
    61. 66. Altered level of consciousness <ul><li>Assessment </li></ul><ul><li>Orientation to time, place and person </li></ul><ul><li>Motor function </li></ul><ul><ul><li>Decerebrate </li></ul></ul><ul><ul><li>Decorticate </li></ul></ul><ul><li>Sensory function </li></ul>
    62. 67. Altered level of consciousness <ul><li>ASSESSMENT </li></ul><ul><li>Behavioral changes initially </li></ul><ul><li>Pupils are slowly reactive </li></ul><ul><li>Then , patient becomes unresponsive and pupils become fixed dilated </li></ul><ul><li>Glasgow Coma Scale is utilized </li></ul>
    63. 68. Altered level of consciousness <ul><li>Nursing Intervention </li></ul><ul><li>1. Maintain patent airway </li></ul><ul><li>Elevate the head of the bed to 30 degrees </li></ul><ul><li>Suctioning </li></ul><ul><li>2. Protect the patient </li></ul><ul><li>Pad side rails </li></ul><ul><li>Prevent injury from equipments, restraints and etc. </li></ul>
    64. 69. Altered level of consciousness <ul><li>Nursing Intervention </li></ul><ul><li>3. Maintain fluid and nutritional balance </li></ul><ul><li>Input and output monitoring </li></ul><ul><li>IVF therapy </li></ul><ul><li>Feeding through NGT </li></ul><ul><li>4. Provide mouth care </li></ul><ul><li>Cleansing and rinsing of mouth </li></ul><ul><li>Petrolatum on the lips </li></ul>
    65. 70. Altered level of consciousness <ul><li>Nursing Intervention </li></ul><ul><li>5. Maintain skin integrity </li></ul><ul><li>Regular turning every 2 hours </li></ul><ul><li>30 degrees bed elevation </li></ul><ul><li>Maintain correct body alignment by using trochanter rolls, foot board </li></ul><ul><li>6. Preserve corneal integrity </li></ul><ul><li>Use of artificial tears every 2 hours </li></ul>
    66. 71. Altered level of consciousness <ul><li>Nursing Intervention </li></ul><ul><li>7. Achieve thermoregulation </li></ul><ul><li>Minimum amount of beddings </li></ul><ul><li>Rectal or tympanic temperature </li></ul><ul><li>Administer acetaminophen as prescribed </li></ul><ul><li>8. Prevent urinary retention </li></ul><ul><li>Use of intermittent catheterization </li></ul>
    67. 72. Altered level of consciousness <ul><li>Nursing Intervention </li></ul><ul><li>9. Promote bowel function </li></ul><ul><li>High fiber diet </li></ul><ul><li>Stool softeners and suppository </li></ul><ul><li>10. Provide sensory stimulation </li></ul><ul><li>Touch and communication </li></ul><ul><li>Frequent reorientation </li></ul>
    68. 73. HEADACHE
    69. 74. Headache <ul><li>Is a clinical manifestation rather than a disease </li></ul><ul><li>Head pain is caused by stimulation of pain sensitive structures in the head </li></ul><ul><li>Affects more than 45 million individuals annually </li></ul><ul><li>Classified as: </li></ul><ul><ul><li>Primary headache- no organic cause </li></ul></ul><ul><ul><li>Secondary headache- with organic cause </li></ul></ul>
    70. 75. Headache <ul><li>Cephalalgia </li></ul><ul><li>Types: </li></ul><ul><ul><li>Migraine headache </li></ul></ul><ul><ul><ul><li>periodic attacks of headache due to vascular disturbance </li></ul></ul></ul><ul><ul><li>Tension headache </li></ul></ul><ul><ul><ul><li>the most common type- due to muscle tension </li></ul></ul></ul>
    71. 76. <ul><li>Types: </li></ul><ul><ul><li>Tension type </li></ul></ul><ul><ul><ul><li>Most common type </li></ul></ul></ul><ul><ul><ul><li>Characterized by a steady pressure in the head </li></ul></ul></ul><ul><ul><ul><li>Generally bilateral </li></ul></ul></ul><ul><ul><ul><li>Referred to as muscle contraction, psychogenic or rheumatic headache </li></ul></ul></ul><ul><ul><ul><li>no aura (the perception of a strange light, an unpleasant smell or confusing thoughts or experiences ) </li></ul></ul></ul><ul><ul><ul><li>May occur daily </li></ul></ul></ul>Headache
    72. 77. <ul><li>Types: </li></ul><ul><ul><li>Tension type </li></ul></ul><ul><ul><ul><li>Manifestations: </li></ul></ul></ul><ul><ul><ul><ul><li>Photophobia </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Phonophobia </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Pressure or tightness bilaterally </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Worse with activity </li></ul></ul></ul></ul>Headache
    73. 78. <ul><li>Type: </li></ul><ul><ul><li>Migraine </li></ul></ul><ul><ul><ul><li>Characterized by unlilateral or bilateral throbbing pain </li></ul></ul></ul><ul><ul><ul><li>Maybe be preceded by prodrome and aura (sensation of light/warmth) </li></ul></ul></ul><ul><ul><ul><li>Aura may last for 30 minutes </li></ul></ul></ul><ul><ul><ul><li>Etiology unknown b maybe neurological, vascular or chemical </li></ul></ul></ul><ul><ul><ul><li>May be triggered by chocolate, alcohol, bright lights, menstruation or stress </li></ul></ul></ul><ul><ul><ul><li>May last for hour to days </li></ul></ul></ul><ul><ul><ul><li>Generally occurs after awakening and improves with sleep </li></ul></ul></ul>Headache
    74. 79. <ul><li>Type: </li></ul><ul><ul><li>Migraine with aura </li></ul></ul><ul><ul><ul><li>Manifestations: </li></ul></ul></ul><ul><ul><ul><ul><li>Unilateral numbness, tingling, or burning sensations in the lips, hands, or face </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Dizziness </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Confusion </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Weakness </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Scintillating scotomata (perceived flashing light in 1 quadrant or visual field) </li></ul></ul></ul></ul>Headache
    75. 80. <ul><li>Type: </li></ul><ul><ul><li>Migraine without aura </li></ul></ul><ul><ul><ul><li>Manifestations: </li></ul></ul></ul><ul><ul><ul><ul><li>Unilateral, severe, pulsating head pain that is worse with activity </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Nausea and vomiting </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Photophobia </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Phonophobia </li></ul></ul></ul></ul>Headache
    76. 81. headache <ul><li>Migraine </li></ul><ul><li>Prodrome stage </li></ul><ul><li>Aura phase </li></ul><ul><li>Headache </li></ul><ul><li>Recovery phase </li></ul>
    77. 82. <ul><li>Type: </li></ul><ul><ul><li>Cluster </li></ul></ul><ul><ul><li>Episodic headaches peaking in 10 minutes anf lasting 90 minutes occurring for weeks or months followed by remission </li></ul></ul><ul><ul><li>Generally occurs unilaterally around or behind one eye and is severe </li></ul></ul><ul><ul><li>More frequent in men between the ages of 20-50 y.o. </li></ul></ul><ul><ul><li>Characterized by an abrupt onset without a prodrome </li></ul></ul>Headache
    78. 83. Neurological Problems <ul><li>Headache </li></ul><ul><ul><li>Vascular – migraine, cluster, hypertensive </li></ul></ul><ul><ul><li>Tension – stress </li></ul></ul><ul><ul><li>Traction-inflammatory – infection, occlusion vessels </li></ul></ul>
    79. 84. <ul><li>Diagnostic testw </li></ul><ul><ul><li>Complete history and physical </li></ul></ul><ul><ul><li>CT scan or MRI if there is neurological abnormality on assessment </li></ul></ul>Headache
    80. 85. headache <ul><li>Nursing Interventions </li></ul><ul><li>1. Avoid precipitating factors </li></ul><ul><li>2. modify lifestyle </li></ul><ul><li>3. relieve pain by pharmacologic measures </li></ul><ul><ul><li>Beta-blockers </li></ul></ul><ul><ul><li>Serotonin antagonists- “triptan&quot; </li></ul></ul>
    81. 86. <ul><li>Nursing Interventions </li></ul><ul><ul><li>Biofeedback </li></ul></ul><ul><ul><li>Relaxation therapy </li></ul></ul><ul><ul><li>Stress management </li></ul></ul><ul><ul><li>Provide the client medication instructions </li></ul></ul><ul><ul><li>Encourage the client to keep a diary of the characteristics of the headaches </li></ul></ul><ul><ul><li>Instruct to avoid trigger-producing foods (caffeine, alcohol, cheese, chocolate, onions, ice cream, salt, vinegar-containing products and nicotine) </li></ul></ul>
    82. 87. Seizures
    83. 88. SEIZURES <ul><li>Episodes of abnormal motor, sensory, autonomic activity resulting from sudden excessive discharge from cerebral neurons </li></ul><ul><li>A part or all of the brain may be involved </li></ul>
    84. 89. SEIZURES <ul><li>PATHOPHYSIOLOGY </li></ul><ul><li>An electrical disturbance in the nerve cells in one brain section  EMITS ELECTRICAL IMPULSES excessively </li></ul>
    85. 90. SEIZURES <ul><li>ETIOLOGIC FACTORS </li></ul><ul><li>Idiopathic </li></ul><ul><li>Fever </li></ul><ul><li>Head injury </li></ul><ul><li>CNS infection </li></ul><ul><li>Metabolic and toxic conditions </li></ul>
    86. 91. Seizures <ul><li>Generalized: </li></ul><ul><ul><li>Tonic-clonic – grand mal </li></ul></ul><ul><ul><li>Absence - Petit mal </li></ul></ul><ul><ul><li>Myoclonic </li></ul></ul><ul><ul><li>Atonic or akinetic </li></ul></ul><ul><li>Localized: (Focal) </li></ul><ul><ul><li>Partial (Jacksonian) </li></ul></ul><ul><ul><li>Psychomotor </li></ul></ul>
    87. 92. Seizures <ul><li>Causes: </li></ul><ul><ul><li>Hypoglycemia </li></ul></ul><ul><ul><li>Infection </li></ul></ul><ul><ul><li>Electrolyte imbalance </li></ul></ul><ul><ul><li>Trauma </li></ul></ul><ul><ul><li>IIP </li></ul></ul><ul><ul><li>Toxins </li></ul></ul>
    88. 93. Seizure Medications <ul><li>Dilantin (Phenytoin) </li></ul><ul><li>Phenobarbital </li></ul><ul><li>Mysoline </li></ul><ul><li>Tridione </li></ul><ul><li>Valium (Diazepam) </li></ul><ul><li>Depakene </li></ul><ul><li>Clonopin </li></ul><ul><li>Mesantoin </li></ul><ul><li>Neurontin </li></ul><ul><li>Lamictal </li></ul><ul><li>Felbatol </li></ul><ul><li>Cerebyx </li></ul>
    89. 94. SEIZURES <ul><li>Nursing Interventions </li></ul><ul><li>During seizure </li></ul><ul><li>1. remove harmful objects from the patient’s surrounding </li></ul><ul><li>2. ease the client to the floor </li></ul><ul><li>3. protect the head with pillows </li></ul><ul><li>4. Observe and note for the duration, parts of body affected, behaviors before and after the seizure </li></ul>
    90. 95. SEIZURES <ul><li>Nursing Interventions </li></ul><ul><li>During seizure </li></ul><ul><li>5. loosen constrictive clothing </li></ul><ul><li>6. DO NOT restrain, or attempt to place tongue blade or insert oral airway </li></ul>
    91. 96. SEIZURES <ul><li>Nursing Interventions </li></ul><ul><li>POST seizure </li></ul><ul><li>1. place patient to the side to drain secretions and prevent aspiration </li></ul><ul><li>2. help re-orient the patient if confused </li></ul><ul><li>3. provide care if patient became incontinent during the seizure attack </li></ul><ul><li>4. stress importance of medication regimen </li></ul>
    92. 97. Seizure Medications <ul><li>Nursing: </li></ul><ul><ul><li>Medications </li></ul></ul><ul><ul><li>Continue meds </li></ul></ul><ul><ul><li>Medic alert ID </li></ul></ul><ul><ul><li>Avoid alcohol, avoid driving, get adequate rest </li></ul></ul><ul><ul><li>If on Dilantin, instruct on oral hygiene </li></ul></ul>
    93. 98. Seizures: Nursing Care <ul><li>Protect </li></ul><ul><ul><li>Lower to the floor; pad side rails; pillow under head; don’t restrain </li></ul></ul><ul><ul><li>No bite block or padded tongue blade </li></ul></ul><ul><ul><li>Allow for post-ictal rest </li></ul></ul><ul><li>Prevent aspiration (airway) </li></ul><ul><ul><li>Turn side; loosen clothing around neck </li></ul></ul><ul><li>Document everything </li></ul>
    94. 99. EPILEPSY <ul><li>A group of syndromes characterized by recurring seizures </li></ul><ul><li>CAUSES </li></ul><ul><li>1. idiopathic 6. brain tumors </li></ul><ul><li>2. Birth trauma 7. head Injury </li></ul><ul><li>3. perinatal infection 8. metabolic disorders </li></ul><ul><li>4. infectious disease 9. CVA </li></ul><ul><li>5. ingestion of toxins </li></ul>
    95. 101. EPILEPSY <ul><li>Recurring seizures may be classified as GENERALIZED or PARTIAL SEIZURES </li></ul><ul><li>Generalized Seizures- cause a generalized electrical abnormality within the brain </li></ul><ul><li>Partial seizures- these seizures arise from a localized part of the brain and cause specific symptoms </li></ul>
    96. 102. GENERALIZED SEIZURES <ul><li>1. General Tonic-Clonic seizure- ( Grand mal ) characterized by loss of consciousness and alternating movements of the extremities </li></ul><ul><li>2. Absence Seizure ( Petit mal )- common in children, begins with a brief change in the LOC, indicated by blinking, rolling of eyes and blank stares </li></ul>
    97. 103. GENERALIZED SEIZURES <ul><li>3. Myoclonic seizure- characterized by brief, involuntary muscular jerks of body extremities </li></ul><ul><li>4. Akinetic seizure- general loss of postural tone and a temporary loss of consciousness- a drop attack </li></ul>
    98. 105. PARTIAL SEIZURES <ul><li>1. Simple partial seizure- typically limited to one cerebral hemisphere </li></ul><ul><li>2. Complex partial seizure- begins with an aura, then with impaired consciousness, with purposeless behaviors like lip-smacking, chewing movements </li></ul>
    99. 106. Epilepsy <ul><li>DIAGNOSTIC TESTS </li></ul><ul><li>1. EEG </li></ul><ul><li>2. CT </li></ul><ul><li>3. MRI </li></ul><ul><li>4. LP </li></ul><ul><li>5. Angiography </li></ul>
    100. 107. Epilepsy <ul><li>Medical treatment </li></ul><ul><li>1. Anticonvulsants- most commonly phenytoin, phenobarbital and carbamazepine </li></ul><ul><li>Ethosuximide and valproic acid for absence seizure </li></ul><ul><li>2. surgery </li></ul>
    101. 108. Epilepsy <ul><li>Nursing Intervention </li></ul><ul><li>1. Care of patients during seizure </li></ul><ul><li>2. care of patients after seizures </li></ul><ul><li>3. patient teaching </li></ul>
    103. 110. What is Epilepsy? <ul><li>Epilepsy is a seizure disorder resulting from sudden bursts of electrical energy in the brain. These electrical discharges produce seizures which vary from one person to another in frequency and form. Sometimes the electrical signal only reaches part of the brain where a part of the body, like an arm or a leg may move on its own. If the signal goes through all of the brain, the person may shake all over, fall and lose consciousness. </li></ul><ul><li>It is not a disease, psychological disorder or contagious . </li></ul><ul><li>Please view the Video ‘ All about Epilepsy’ </li></ul><ul><li> </li></ul>
    104. 111. Epilepsy and GABA <ul><li>A seizure occurs when the message delivery system becomes unbalanced. </li></ul><ul><li>Under normal circumstances, the neurotransmitter GABA (gamma-amino </li></ul><ul><li>butryic acid) triggers signals. </li></ul><ul><li>When there is not enough GABA, a person has a seizure because the </li></ul><ul><li>receiving neurons is flooded with signals. </li></ul>
    105. 112. <ul><li>SEIZURE </li></ul><ul><li>sudden, excessive, disorderly electrical discharges of the neurons. </li></ul><ul><li>EFFECTS OF SEIZURE: alteration in the following </li></ul><ul><li>mental status </li></ul><ul><li>LOC </li></ul><ul><li>sensory and special senses </li></ul><ul><li>motor funtion </li></ul><ul><li>CLASSIFICATION OF SEIZURES </li></ul><ul><li>A. Primary Generalized Seizure </li></ul><ul><li>B. Partial Seizure </li></ul><ul><li>GENERALIZED SEIZURES: </li></ul><ul><li>GRAND MAL (Tonic-Clonic) </li></ul><ul><li>most common type of seizure </li></ul><ul><li>The phases are as follows: </li></ul><ul><li>The phases are as follows: </li></ul>
    106. 114. <ul><li>PETIT MAL (Absence Seizure or Little Sickness) </li></ul><ul><li>not preceeded by AURA </li></ul><ul><li>little or no tonic-clonic </li></ul><ul><li>characteristic: blank facial expression, automatism like lip-chewing, cheek smacking </li></ul><ul><li>regain of consciousness as rapid as it was for 10-20secs </li></ul><ul><li>usually occurs during childhood and adolescence </li></ul><ul><li>JACKSONIAN / FOCAL SEIZURE </li></ul><ul><li>common for patients with organic brain lesion like frontal lobe tumor </li></ul><ul><li>aura is present(numbness, tingling, crawling feeling) </li></ul><ul><li>charac by tonic-clonic movements of group muscle e.g. hands, foot, or face then it proceeds to grand mal seizure </li></ul><ul><li>FEBRILE SEIZURE </li></ul><ul><li>this is common for children 6 mos to <5yo, when temp. is rising </li></ul><ul><li>PSYCHOMOTOR SEIZURE </li></ul><ul><li>aura is present (hallucinations or illusion) </li></ul><ul><li>charac by mental clouding (being out of touch with the envt) </li></ul><ul><li>appears intoxicated </li></ul><ul><li>the client may commit violent or antisocial acts, e.g. Going naked public, running </li></ul>
    107. 115. PARTIAL SEIZURE 2 TYPES OF PARTIAL SEIZURES: A. Simple Partial Seizure B. Complex Partial Seizure <ul><li>Simple Partial Seizure </li></ul><ul><li>Awareness Preserved </li></ul><ul><li>Memory Preserved </li></ul><ul><li>Consciousness Preserved </li></ul>
    108. 116. <ul><li>Complex Partial Seizure </li></ul><ul><li>Awareness Preserved </li></ul><ul><li>Memory Preserved </li></ul><ul><li>Consciousness Preserved </li></ul>
    109. 117. <ul><li>CAUSES OF SEIZURES IN CHILDREN </li></ul><ul><li>Birth Traumas </li></ul><ul><li>Infections – Meningitis </li></ul><ul><li>Congenital Abnormalities </li></ul><ul><li>High Fever </li></ul><ul><li>CAUSES OF SEIZURES IN MIDDLE YEARS </li></ul><ul><li>Head Injuries </li></ul><ul><li>Infections </li></ul><ul><li>Alcohol </li></ul><ul><li>Stimulant Drugs </li></ul><ul><li>Medications its Side Effects </li></ul><ul><li>CAUSES OF SEIZURES IN THE ELDERLY </li></ul><ul><li>Brain Tumors </li></ul><ul><li>Strokes </li></ul>
    110. 118. <ul><li>CHEMICAL IMBALANCES CAUSE SEIZURE </li></ul><ul><li>Alcohol </li></ul><ul><li>Cocaine </li></ul><ul><li>Other Drugs </li></ul><ul><li>Low blood sugar, low oxygen, low blood sodium, low calcium, kidney and renal failure </li></ul>
    111. 119. Nursing Management During a Seizure <ul><li>The nursing goal is to prevent injury to the patient. This includes not only physical support but psychological support as well. </li></ul><ul><li>Provide privacy </li></ul><ul><li>Ease the patient on the floor, if possible </li></ul><ul><li>Protect the head with a pad to prevent injury </li></ul><ul><li>Loosen constrictive clothing </li></ul><ul><li>If aura precedes the seizure, place a padded tongue blade between the teeth </li></ul><ul><li>Do not attempt to pry open jaws that are clenched in a spasm to insert anything </li></ul><ul><li>No attempt should be made to restrain the patient during the seizure </li></ul><ul><li>Place the patient on one side with head flexed forward </li></ul><ul><li>The patient should be reoriented to the environments and happening upon awakening </li></ul>
    112. 120. Nursing Assessment during a Seizure <ul><li>Observe and to record the sequence of symptoms. </li></ul><ul><li>Description of the circumstances before the attack. </li></ul><ul><li>The first thing a patient does in an attack. </li></ul><ul><li>The type of movements in the part of the body involved. </li></ul><ul><li>The size of both pupils. </li></ul><ul><li>Whether or not there is automatisms </li></ul><ul><li>Duration of each phase of the attack </li></ul><ul><li>Unconsciousness, ability to speak, consciousness </li></ul>
    113. 121. Epilepsy <ul><li>Disorders of brain function characterized by recurring seizures. </li></ul><ul><li>Disturbance in consciousness, movement, behavior, mood, sensation, perception. It is not a disease but a symptom. </li></ul><ul><li>Electrical disturbance in one section of nerve cells causing uncontrolled electrical discharges. </li></ul>
    114. 122. How is Epilepsy Diagnosed? <ul><li>History </li></ul><ul><li>Physical Exam </li></ul><ul><li>Electroencephalogram </li></ul><ul><li>MRI (Neuro-imaging) </li></ul><ul><li>CT Scan </li></ul>
    115. 123. 6 Truths about Epilepsy <ul><li>Not to be called epileptic but a person with a seizure disorders </li></ul><ul><li>In epilepsy there might be seldom brain damage, brain function is disturb by seizure </li></ul><ul><li>Difference level of Intelligence </li></ul><ul><li>Violence does not follow epilepsy </li></ul><ul><li>Non usually inherited – cause is unknown and usually associated with environmental causes </li></ul><ul><li>Epilepsy is not a curse, it is a medical condition </li></ul>
    116. 124. Nursing Diagnoses <ul><li>Fear related to the ever-present possibility of having seizures </li></ul><ul><li>Ineffective coping related to stresses imposed by epilepsy </li></ul><ul><li>Knowledge deficit about epilepsy and its control </li></ul><ul><li>High risk for injury during seizures </li></ul>
    117. 125. <ul><li>Goals: </li></ul><ul><li>Short Term Goals: </li></ul><ul><li>Maintenance of control of seizures </li></ul><ul><li>Achievement of a satisfactory psychosocial adjustment </li></ul><ul><li>Acquisition of knowledge and understanding about the condition </li></ul><ul><li>Long Term Goals: </li></ul><ul><li>To achieve a satisfactory life adjustment </li></ul><ul><li>To prevent or manage episodes of status epilepticus </li></ul><ul><li>Nursing Interventions: </li></ul><ul><li>Seizure Control </li></ul><ul><li>Improved Coping Mechanisms </li></ul><ul><li>Patient Education </li></ul>
    118. 126. STATUS EPILEPTICUS <ul><li>(ACUTE PROLONGED SEIZURE ACTIVITY) </li></ul><ul><li>IS A SERIES OF GENERALIZED SEIZURE THAT OCCUR WITHOUT FULL RECOVERY OF CONSCIOUSNESS BETWEEN ATTACKS </li></ul><ul><li>THE TERM HAS BEEN BROADENED TO INCLUDE CONTINUOUS CLINICAL OR ELECTRICAL SEIZURES LASTING AT LEAST 30 MINUTES, EVEN WITHOUT IMPAIRMENT OF CONSCIOUSNESS. </li></ul><ul><li>Happens when there is an abrupt cessation of anticonvulsant drugs/ethanol </li></ul><ul><li>A seizure is a sudden disruption of the brain's normal electrical activity, which can cause a loss of consciousness and make the body twitch and jerk. This condition is a medical emergency. </li></ul>
    119. 127. CAUSES <ul><li>Not taking anticonvulsant medication </li></ul><ul><li>Also caused by an underlying condition, such as meningitis, sepsis, encephalitis, brain tumor, head trauma, extremely high fever, low glucose levels, or exposure to toxins. </li></ul>
    120. 128. Symptoms <ul><li>seizures occurring so frequently that they appear to be one continuous seizure. </li></ul><ul><li>These seizures include severe muscle contractions and difficulty breathing . Permanent damage can occur to the brain and heart if treatment is not immediate. </li></ul><ul><li>A person's symptoms can range from simply appearing dazed to the more serious muscle contractions, spasms, and loss of consciousness. </li></ul><ul><li>The specific symptoms depend on the underlying type of seizure. </li></ul>
    121. 129. TWO CATEGORIES OF STATUS EPILEPTICUS <ul><li>CONVULSIVE </li></ul><ul><li>Epilepsia partialis continua is a variant it involve an hour, day or even week-long jerking. It is a consequence of vascular disease, tumor or encephalitis and drug resistant. </li></ul><ul><li>NONCONVULSIVE </li></ul><ul><li>Complex Partial Status Epilepticus CPSE and absence status epilepticus are rare forms of the condition which are marked by nonconvulsive seizures. </li></ul><ul><li>The seizure is confined to a small area of the brain, normally the temporal lobe. But the latter, status epilepticus, is marked by a generalised seizure affecting the whole brain, and an EEG is needed to differentiate between the two conditions. </li></ul><ul><li>This results in episodes characterized by a long-lasting stupor, staring and unresponsiveness. </li></ul>
    122. 130. NURSING DIAGNOSIS <ul><li>High Risk for Injury r/t Seizure Activity </li></ul><ul><li>Individual Coping r/t perceive social stigma, potential changes in employment </li></ul>
    123. 131. HOW IT IS DIAGNOSED? <ul><li>Status epilepticus is diagnosed according to its characteristics symptoms. The doctor will order test to look for the cause of the seizures. This may include: </li></ul><ul><li>Blood test </li></ul><ul><li>ECG to check for an abnormal heart rhythm </li></ul><ul><li>EEG to check electrical activity in the brain </li></ul><ul><li>MRI or CT scan to check for braing tumors or signs of damage to the brain tissue. </li></ul>
    124. 132. MEDICATIONS <ul><li>Diazepam (Valium) this will stop motor movement </li></ul><ul><li>Phenytoin (Dilatin) </li></ul><ul><li>Phenobarbital (Barbita) </li></ul><ul><li>Paraldehyde </li></ul><ul><li>Thiopenthal sodium (Pentotal sodium) </li></ul><ul><li>General anesthesia may also be used as a treatment of last resort to stop seizure activity </li></ul>
    125. 133. NURSING INTERVENTIONS <ul><li>PREVENTING INJURY </li></ul><ul><li> </li></ul><ul><li>REDUCING FEARS OF SEIZURE </li></ul><ul><li>IMPROVING COPING MECHANISMS </li></ul><ul><li>PROVIDING PATIENT AND FAMILY </li></ul><ul><li>EDUCATION </li></ul><ul><li>MONITORING AND MANAGING POTENTIAL COMPLICATIONS </li></ul><ul><li>TEACHING PATIENTS SELF-CARE </li></ul>
    126. 134. PREVENTING INJURY <ul><li>Injury prevention for the patient with seizure is a PRIORITY. </li></ul><ul><ul><li>patient should be placed on the floor and remove any obstructive items </li></ul></ul><ul><ul><li>patient should never be forced into a position </li></ul></ul><ul><ul><li>pad side rails </li></ul></ul><ul><ul><li>do not attempt to try to open jaws that are clenched in a spasm to insert anything. </li></ul></ul><ul><ul><li>if possible place the patient on one side with head flexed forward </li></ul></ul>
    127. 135. PATIENT EDUCATION <ul><li>TAKE MEDICATION AT REGULAR BASIS </li></ul><ul><li>AVOID ALCOHOL. Lowers seizure threshold </li></ul><ul><li>ADEQUATE REST </li></ul><ul><li>WELL-BALANCED DIET </li></ul><ul><li>AVOID DRIVING, OPERATING MACHINES, SWIMMING UNTIL SEIZURES ARE WELL CONTROLLED. </li></ul><ul><li>LIVE AN ACTIVE LIFE </li></ul>
    128. 136. REDUCING FEARS OF SEIZURE <ul><li>Fear that a seizure may occur unexpectedly can be reduced </li></ul><ul><li>by the patients adherence to the prescribed treatment regimen. </li></ul><ul><li>Cooperation of the patient and family and their trust in the prescribed regimen are essential for control of seizures. </li></ul><ul><li>Periodic monitoring is necessary to ensure the adequacy of the treatment regimen and to prevent the side effects. . </li></ul>
    129. 137. IMPROVING COPING MECHANISMS <ul><li>It has been noted that the social, psychological, and behavioral problems frequently accompanying the attack can be more handicap than the actual seizure. </li></ul><ul><li>Counselling assists the individual and family to understand the condition and the limitations imposed by it. </li></ul><ul><li>Social and recreational opportunities are good for mental health . </li></ul><ul><li>Nurses can improve the quality of life for patients with the disorder by educating them and their family about the symptom and also the management. </li></ul>
    130. 138. PROVIDING PATIENT AND FAMILY EDUCATION <ul><li>Ongoing education and encouragement should be given to patients to enable them to overcome these feelings. </li></ul><ul><li>The patient and family should be educated about the medications as well as care during a seizure. </li></ul><ul><li>Perhaps the most valuable facets are education and efforts to modify the attitudes of the patient and family toward the disorder. </li></ul>
    131. 139. MONITORING AND MANAGING POTENTIAL COMPLICATIONS <ul><li>Patients should have plan to have serum drug levels drawn at regular intervals. </li></ul><ul><li>The patient and family are instructed about the side effects and are given specific guidelines to assess and report signs and symptoms indicating medication overdose. </li></ul>
    132. 140. Anticonvulsant drugs – phenytoin (Dilantin) <ul><li>A loading dose is needed to reach therapeutic levels more quickly. </li></ul><ul><li>When given through IV route, mix the drug with saline solution ONLY. Dextrose causes an insoluble precipitate to form </li></ul><ul><li>Therapeutic Level: </li></ul><ul><ul><li>10-20 mg/dl </li></ul></ul><ul><li>Given 1 hr before or 2 hrs after meal (like NGT feeding) </li></ul><ul><li>Nutritional supplements like vitamins, milk products and alcohol interfere absorption of the drug </li></ul><ul><li>Adverse effect: </li></ul><ul><ul><li>Sedation </li></ul></ul><ul><ul><li>Drowsiness </li></ul></ul><ul><ul><li>Gingival hyperplasia </li></ul></ul><ul><ul><li>Blood dyscrasia </li></ul></ul><ul><ul><li>Toxicity </li></ul></ul><ul><ul><ul><li>Confusion and ataxia </li></ul></ul></ul>
    133. 141. TEACHING PATIENTS SELF CARE <ul><li>Like thorough oral hygiene after each meal, gum massage, daily flossing, and regular dental care. </li></ul><ul><li>The patient is also instructed to inform all health care providers of the medication being taken because of the possibility of drug interactions. An individualized comprehensive teaching plan is needed to assist the patient and family to adjust to this chronic disorder. </li></ul>
    134. 142. Autonomic Dysreflexia/ Hyperreflexia
    135. 143. Definition <ul><li>A sudden nervous system response to a condition that irritates the body </li></ul><ul><li>It can happen to people with a spinal cord injury at the thoracic (T) 6 level or higher </li></ul><ul><li>common </li></ul><ul><li>It is a MEDICAL EMERGENCY that raises the blood pressure so high, that it can cause death if not taken care of right away </li></ul><ul><li>AKA Autonomic hyperreflexia, dysreflexia, A/D </li></ul>
    136. 144. Causes <ul><li>Full bladder </li></ul><ul><li>Full bowel or constipation </li></ul><ul><li>Bladder infection or bladder stones </li></ul><ul><li>Tests done on the bladder </li></ul><ul><li>Pressure sores </li></ul><ul><li>Ingrown toenails </li></ul><ul><li>Labour and delivery </li></ul><ul><li>Genital stimulation (or pressure) </li></ul><ul><li>Ejaculation </li></ul><ul><li>Tight clothing or shoes </li></ul><ul><li>Severe menstrual cramps </li></ul><ul><li>Fractures bones (traumatic pain) </li></ul>
    137. 145. Causes <ul><li>Abdominal medical problems </li></ul><ul><ul><li>Gall stones </li></ul></ul><ul><ul><li>Appendicitis </li></ul></ul><ul><ul><li>Kidney stomes </li></ul></ul><ul><ul><li>ulcers </li></ul></ul><ul><li>Hot and cold temperatures </li></ul><ul><li>Sunburn </li></ul><ul><li>Some drugs </li></ul><ul><ul><li>e.g. digoxin </li></ul></ul>
    138. 146. Common Symptoms <ul><li>Sudden severe rise in blood pressure </li></ul><ul><li>Pounding headache </li></ul><ul><li>Change in heart rate </li></ul><ul><li>Flushed skin above level of injury </li></ul><ul><li>Sweating above or below level of injury </li></ul><ul><li>An “aura” </li></ul><ul><li>Anxious feeling </li></ul><ul><li>Blurred vision </li></ul><ul><li>Stuffy nose </li></ul><ul><li>Shivering above level of injury </li></ul><ul><li>Goose bumps below level of injury </li></ul><ul><li>Pale skin below level of injury </li></ul>
    139. 147. Wallet Sized Card Autonomic Dysreflexia (AD) AD is a potentially life threatening complication of spinal cord injury above T7 level. It is caused by an unopposed sympathetic nervous system response to noxious stimulation below the level of the injury. Blood pressure may rise dangerously. The most typical cause of AD is distended bladder. Other causes could be distended bowel, pressure sore, in-grown toenail, etc. <ul><li>Autonomic Dysreflexia Management </li></ul><ul><li>Raise the head of the bed by 90  or sit person upright. </li></ul><ul><li>Monitor BP every 5 minutes. </li></ul><ul><li>Check for sources of AD: drain bladder first, consider using topical anesthetic jelly for lubrication of catheter. </li></ul><ul><li>Check rectum for stool. Apply anesthetic jelly to rectal wall before manipulation. Use digital stimulation to promote reflex defecation. </li></ul><ul><li>Check for other sources of AD such as ulcer, fracture, in-grown toenail, etc. </li></ul><ul><li>If SBP is above 150 mmHg after above checks, give captopril 25 mg sublingually x1. Advise patient to avoid swallowing until tablet dissolved. </li></ul><ul><li>If SBP still greater than 150 mmHG at 30 minutes post-captropril then give immediate release nifedipine 5 mg capsule via the bite and wallow method. </li></ul><ul><li>****ONLY IN A HOSPITAL SETTING**** </li></ul><ul><li>Repeat nifedipine 5 mg bite and swallow 15 minutes after the initial nifedipine dose if SBP still greater than 150 mmHg. </li></ul><ul><li>Consider intravenous agents for hypertension if hypertension is refractory. </li></ul><ul><li>Symptoms may include: </li></ul><ul><li>elevated blood pressure </li></ul><ul><li>Headache </li></ul><ul><li>Sweating </li></ul><ul><li>flushed face </li></ul><ul><li>Anxiety </li></ul><ul><li>bradycardia. </li></ul><ul><li>Treatment is to remove the cause. Once the cause is removed the BP will return to normal immediately. </li></ul>
    140. 148. Nursing Interventions <ul><li>Sit up if lying down – this will decrease our blood pressure </li></ul><ul><li>Find and remove the cause – it usually will NOT go away until the cause is removed or corrected </li></ul><ul><li>Loosen tight clothing, legbag straps, shoes </li></ul>
    141. 149. <ul><li>Check for BLADDER problems </li></ul><ul><ul><li>empty bladder with in/out catheter </li></ul></ul><ul><ul><li>check for kinks in tubing </li></ul></ul><ul><ul><li>check for full legbag </li></ul></ul><ul><ul><li>change foley catheter </li></ul></ul>
    142. 150. <ul><li>Check for BOWEL problems </li></ul><ul><ul><li>Do rectal check: if there is stool, remove it gently. </li></ul></ul><ul><ul><li>Use xylocaine gel to decrease potential stimulation which could cause BP to increase even more </li></ul></ul>
    143. 151. <ul><li>Check for SKIN problems </li></ul><ul><ul><li>Do a thorough check of the skin from top to bottom, front to back </li></ul></ul><ul><ul><li>Check buttocks, feet, toenails, etc </li></ul></ul><ul><ul><li>Use a mirror and/or get help from someone </li></ul></ul>
    144. 152. Run Down on Autonomic Dysreflexia
    145. 153. Autonomic Dysreflexia/hyperreflexia <ul><li>Seen commonly in spinal cord injury above T6 </li></ul><ul><li>An exaggerated response by the autonomic system resulting from various stimuli most commonly distended bladder, impacted feces, pain, skin irritation </li></ul>
    146. 154. Autonomic Dysreflexia/hyperreflexia <ul><li>Clinical MANIFESTATIONS </li></ul><ul><li>1. Hypertension </li></ul><ul><li>2. Bradycardia </li></ul><ul><li>3. Severe pounding headache </li></ul><ul><li>4. Diaphoresis </li></ul><ul><li>5. Nausea </li></ul><ul><li>6. Nasal congestion </li></ul>
    147. 155. Autonomic Dysreflexia/hyperreflexia <ul><li>NURSING INTERVENTIONS </li></ul><ul><li>1. Elevate the head of the bed immediately </li></ul><ul><li>2. Check for bladder distention and empty bladder with urinary catheter </li></ul><ul><li>3. Check for Fecal impaction and other triggering factors like skin irritation, pressure ulcer </li></ul><ul><li>4. Administer antihypertensive medications- usually hydralazine </li></ul>
    148. 156. Infection and Inflammation <ul><li>Meningitis </li></ul><ul><li>Encephalitis </li></ul><ul><li>Brain abscess </li></ul><ul><li>Guillain-Barré </li></ul><ul><li>Neurosyphilis </li></ul><ul><li>Poliomyelitis </li></ul><ul><li>Rabies </li></ul><ul><li>Tetanus </li></ul><ul><li>Botulism </li></ul><ul><li>AIDS </li></ul>
    149. 157. Meningitis
    150. 158. Meningitis <ul><li>Acute infection of the meninges </li></ul><ul><li>Viral or bacterial </li></ul><ul><li>Almost any bacteria entering the body can cause meningitis </li></ul>
    151. 159. PATHOPHYSIOLOGY <ul><li>Invasion may occur at choroid plexus or directly thru an opening in the dura </li></ul><ul><li>Organisms colonize in the CSF, leading to inflammation of the meninges that contains it </li></ul><ul><li>Exudate forms, meninges then become thickened, and adhesions form, leading to hydrocephalus. </li></ul><ul><li>Arteries supplying the subarachnoid space maybe inflamed, leading to rupture or thrombosis of these vessels. </li></ul><ul><li>Severe cases, lead to cerebral edema and IICP, vasculitis and cerebral infarction </li></ul>
    152. 160. Manifestations <ul><li>Classical signs: </li></ul><ul><ul><li>Nuchal rigidity </li></ul></ul><ul><ul><li>Brudzinski’s sign </li></ul></ul><ul><ul><li>Kernig’s sign </li></ul></ul><ul><ul><li>Photophobia </li></ul></ul>
    153. 161. Manifestations: <ul><li>Other s/sx: </li></ul><ul><ul><li>Headache </li></ul></ul><ul><ul><li>Fever </li></ul></ul><ul><ul><li>Tachycardia </li></ul></ul><ul><ul><li>N * V </li></ul></ul>
    154. 162. Meningitis-Medical Management <ul><li>Diagnosed by LP </li></ul><ul><li>Medications </li></ul><ul><li>Respiratory isolation </li></ul><ul><li>Cool, dark quiet room </li></ul><ul><li>Maintain hydration </li></ul><ul><li>Prevent injury </li></ul>
    155. 163. Ideal Medical Management Diagnostic Evaluation <ul><li>Complete blood count (CBC) with differential </li></ul><ul><ul><li>detect an elevated leukocyte count in bacterial and viral meningitis </li></ul></ul><ul><li>Lumbar puncture </li></ul><ul><ul><li>elevated CSF pressure </li></ul></ul><ul><ul><li>cloudy or milky white CSF </li></ul></ul><ul><ul><li>high protein level </li></ul></ul><ul><ul><li>positive Gram stain and culture that usually identifies the infecting organism unless it's a virus </li></ul></ul><ul><ul><li>depressed CSF glucose concentration) </li></ul></ul><ul><li>CSF evaluation for pressure, leukocytes, protein, glucose </li></ul>
    156. 164. <ul><li>MRI/CT scan </li></ul><ul><ul><li>with and without contrast rules out cerebral hematoma, hemorrhage, or tumor </li></ul></ul><ul><ul><li>CT scan with contrast - to detect abscesses. </li></ul></ul><ul><li>Low CD4+ counts indicate immunosuppression in HIV-positive patients and other patients with immunosuppressive disorders. </li></ul><ul><li>Latex agglutination may be positive for antigens in meningitis. </li></ul><ul><li>Chest X-rays </li></ul><ul><ul><li>may reveal pneumonitis or lung abscess, tubercular lesions, or granulomas secondary to fungal infection </li></ul></ul>
    157. 165. <ul><li>Lumbar puncture is essential </li></ul><ul><li>Cornerstone in the diagnosis </li></ul><ul><li>should be performed in all cases whenever the diagnosis of meningitis is known or suspected on the basis of clinical signs </li></ul><ul><li>Contraindications to doing a lumbar tap </li></ul><ul><li>1. presence of significant cardio-pulmonary compromise and shock </li></ul><ul><li>2. signs of increased ICP </li></ul><ul><li>3. suspected case of space occupying lesion </li></ul><ul><li>4. infection in the area that the spinal needle will traverse to obtain CSF </li></ul><ul><li>5. hematologic problems </li></ul>Laboratory Diagnosis of Bacterial Meningitis
    158. 166. CSF Findings in Bacterial Meningitis <ul><li>CSF pressure - usually elevated </li></ul><ul><li>CSF cells count and chemistry </li></ul><ul><li>leukocytosis- >1000/cu mm </li></ul><ul><li>% PMN - 90% </li></ul><ul><li>Glucose- <40 mg/dl </li></ul><ul><li>CSF blood to glucose ratio <0.40 </li></ul><ul><li>Protein 50-500 mg/dl </li></ul><ul><li>c. stained smears of CSF </li></ul><ul><li>gram stain - (+) for bacteria </li></ul><ul><li>AFB smear - (-) </li></ul><ul><li>India ink - (-) </li></ul><ul><li>d. CSF culture </li></ul><ul><li>*a negative culture does rule out meningitis </li></ul>
    159. 167. Treatment <ul><li>Team effort: </li></ul><ul><ul><li>Nursing </li></ul></ul><ul><ul><li>infectious diseases specialists </li></ul></ul><ul><ul><li>Neurology </li></ul></ul><ul><ul><li>internal medicine </li></ul></ul><ul><ul><li>otolaryngology specialists </li></ul></ul><ul><ul><li>laboratory and diagnostic staff </li></ul></ul><ul><li>Antibiotic therapy and vigorous supportive care </li></ul><ul><ul><li>I.V. antibiotics are given for at least 2 weeks, followed by oral antibiotics ampicillin, cefotaxime, ceftriaxone, and nafcillin </li></ul></ul><ul><li>Dexamethasone (Decadron) - as adjunctive therapy, to prevent deafness among young children </li></ul><ul><li>Mannitol - to decrease cerebral edema </li></ul><ul><li>Anticonvulsant (usually given I.V.) or a sedative - to reduce restlessness </li></ul><ul><li>Aspirin or acetaminophen - to relieve headache and fever </li></ul>
    160. 168. <ul><li>Supportive measures consist of: </li></ul><ul><ul><li>bed rest </li></ul></ul><ul><ul><li>hypothermia, and </li></ul></ul><ul><ul><li>fluid therapy to prevent dehydration </li></ul></ul><ul><li>Isolation - if nasal cultures are positive </li></ul><ul><li>Therapy for any coexisting conditions, such as endocarditis or pneumonia </li></ul><ul><li>Temozolomide (Temodar) - neoplastic meningitis </li></ul><ul><li>Cochlear implantation rehabilitation - deafness caused by meningitis </li></ul><ul><li>Therapy for S. aureus and gram-negative bacilli - If meningitis is suspected after neurosurgical procedures, potential I.V. line bacteremia, CSF leak, or immunosuppression </li></ul><ul><li>Antifungal agents - for cryptococcal meningitis </li></ul><ul><li>Empiric antituberculosis drugs must be initiated if infection by Mycobacterium tuberculosis is suspected </li></ul>
    161. 169. Nursing Management : <ul><li>Nursing Assessment </li></ul><ul><ul><li>Obtain a history of recent infections such as upper respiratory infection, and exposure to causative agents </li></ul></ul><ul><ul><li>Assess neurologic status and vital signs </li></ul></ul><ul><ul><li>Evaluate for signs of meningeal irritation </li></ul></ul><ul><ul><li>Assess sensorineural hearing loss (vision and hearing), cranial nerve damage (eg, facial nerve palsy), and diminished cognitive function. </li></ul></ul>
    162. 170. Nursing Diagnoses <ul><li>Acute pain related to meningeal irritation </li></ul><ul><li>Anxiety </li></ul><ul><li>Hyperthermia related to the infectious process and cerebral edema </li></ul><ul><li>Impaired gas exchange </li></ul><ul><li>Impaired Physical Mobility related to prolonged bed rest </li></ul><ul><li>Ineffective Tissue Perfusion (cerebral) related to infectious process and cerebral edema </li></ul><ul><li>Risk for deficient fluid volume related to fever and decreased intake </li></ul><ul><li>Risk for impaired skin integrity </li></ul>
    163. 171. Key outcomes: <ul><li>The patient will: </li></ul><ul><ul><li>express feelings of comfort and relief of pain </li></ul></ul><ul><ul><li>identify strategies to reduce anxiety </li></ul></ul><ul><ul><li>exhibit temperature within normal range </li></ul></ul><ul><ul><li>maintain adequate ventilation and oxygenation </li></ul></ul><ul><ul><li>maintain fluid volume within normal range </li></ul></ul><ul><ul><li>Have skin integrity remain intact </li></ul></ul>
    164. 172. Nursing Interventions <ul><li>Reducing Fever </li></ul><ul><ul><li>Administer antimicrobial agents on time to maintain optimal blood levels. </li></ul></ul><ul><ul><li>Monitor temperature frequently or continuously, and administer antipyretics as ordered. </li></ul></ul><ul><ul><li>Institute other cooling measures, such as a hypothermia blanket, as indicated. </li></ul></ul><ul><li>Maintaining Fluid Balance </li></ul><ul><ul><li>Prevent I.V. fluid overload, which may worsen cerebral edema. </li></ul></ul><ul><ul><li>Monitor intake and output closely. </li></ul></ul><ul><ul><li>Monitor CVP frequently. </li></ul></ul>
    165. 173. <ul><li>Enhancing Cerebral Perfusion </li></ul><ul><ul><li>Assess LOC, vital signs, and neurologic parameters frequently. Observe for signs and symptoms of ICP (eg, decreased LOC, dilated pupils, widening pulse pressure). </li></ul></ul><ul><ul><li>Maintain a quiet, calm environment to prevent agitation, which may cause an increased ICP. </li></ul></ul><ul><ul><li>Prepare patient for a lumbar puncture for CSF evaluation, and repeat spinal tap, if indicated. Lumbar puncture typically precedes neuroimaging </li></ul></ul><ul><ul><li>Notify the health care provider of signs of deterioration: increasing temperature, decreasing LOC, seizure activity, or altered respirations. </li></ul></ul><ul><li>Reducing Pain </li></ul><ul><ul><li>Administer analgesics as ordered; monitor for response and adverse reactions. Avoid opioids, which may mask a decreasing LOC. </li></ul></ul><ul><ul><li>Darken the room if photophobia is present. </li></ul></ul><ul><ul><li>Assist with position of comfort for neck stiffness, and turn patient slowly and carefully with head and neck in alignment. </li></ul></ul><ul><ul><li>Elevate the head of the bed to decrease ICP and reduce pain. </li></ul></ul>Nursing Interventions
    166. 174. Nursing Interventions <ul><li>Promoting Return to Optimal Level of Functioning </li></ul><ul><ul><li>Implement rehabilitation interventions after admission (eg, turning, positioning). </li></ul></ul><ul><ul><li>Progress from passive to active exercises based on the patient's neurologic status </li></ul></ul>
    167. 175. Patient Education and Health Maintenance <ul><li>Advice close contacts of the patient with meningitis that prophylactic treatment may be indicated; they should check with their health care providers or the local public health department. </li></ul><ul><li>To help prevent the development of meningitis, teach patients with chronic sinusitis or other chronic infections the importance of proper medical treatment. </li></ul><ul><li>Encourage the patient to follow medication regimen as directed to fully eradicate the infectious agent. </li></ul><ul><li>Encourage follow-up and prompt attention to infections in future. </li></ul><ul><li>Inform patients who have children about the importance of vaccination with measles, mumps, rubella vaccine, H. influenzae type B vaccine, and pneumococcal vaccine as a preventive measure. Vaccination is recommended for children younger than school age. </li></ul>
    168. 176. Expected Outcomes <ul><li>Afebrile </li></ul><ul><li>Adequate urine output; </li></ul><ul><li>CVP in normal range </li></ul><ul><li>Alert LOC; </li></ul><ul><li>normal vital signs </li></ul><ul><li>Pain controlled </li></ul><ul><li>Optimal level of functioning after resolution </li></ul>
    169. 177. Encephalitis
    170. 178. Encephalitis <ul><li>Inflammatory process of CNS with altered function of brain and spinal cord </li></ul><ul><li>Variety of causative organisms—viral most frequent </li></ul><ul><li>Vector reservoir : mosquitoes and ticks </li></ul>
    171. 179. Encephalitis <ul><li>2 forms: </li></ul><ul><li>Primary </li></ul><ul><ul><li>Occurs when a virus invades and replicates within the brain </li></ul></ul><ul><li>Postinfectious (parainfectious) </li></ul><ul><ul><li>Brain inflammation that develops in combination with other viral illness or ff admin of vaccines such as measles, mumps and rubella –due to hypersensitivity reaction that leads to demyelination of nerves </li></ul></ul>
    172. 180. Clinical Manifestations of Encephalitis: Onset Sudden or Gradual <ul><li>Malaise </li></ul><ul><li>Fever </li></ul><ul><li>Headache/dizziness </li></ul><ul><li>Stiff neck </li></ul><ul><li>Nausea/vomiting </li></ul><ul><li>Ataxia </li></ul><ul><li>Speech difficulties </li></ul>
    173. 181. Clinical Manifestations of Severe Encephalitis <ul><li>High fever </li></ul><ul><li>Disorientation/stupor/coma </li></ul><ul><li>Seizures/spasticity </li></ul><ul><li>Ocular palsies </li></ul><ul><li>Paralysis </li></ul><ul><li>IICP </li></ul>
    174. 182. Encephalitis <ul><li>Diagnostic evaluation </li></ul><ul><ul><li>CSF analysis </li></ul></ul><ul><ul><li>EEG </li></ul></ul><ul><ul><li>MRI </li></ul></ul><ul><ul><li>PET </li></ul></ul>
    175. 183. Medical Management <ul><li>Prescribed diuretics – mannitol </li></ul><ul><ul><li>Decrease edema </li></ul></ul><ul><li>Antibiotics – acyclovir (Zovirax) </li></ul><ul><ul><li>for herpes encephalities </li></ul></ul>
    176. 184. <ul><li>Risk for ineffective airway clearance r/y unresponsiveness and inability to clear secretions. </li></ul><ul><li>Ineffective airway clearance </li></ul><ul><li>Altered thought process r/t increased in ICP </li></ul>Nursing Diagnoses
    177. 185. Nursing Intervention <ul><li>Maintain a patent airway </li></ul><ul><ul><li>Assess pupil size and reaction, LOC, strength and motion of the extremities, response to noxious stimuli </li></ul></ul><ul><ul><li>Endotracheal intubation, oxygen therapy and mechanical ventilation </li></ul></ul><ul><ul><li>Ongoing neurological assessment </li></ul></ul><ul><ul><li>Document changes in the pt’s condition and initiates proper care immediately. </li></ul></ul><ul><ul><li>Turn, cough and deep breathe every 2 hours </li></ul></ul>
    178. 186. Nursing Intervention <ul><li>Maintain airway, breathing and circulation </li></ul><ul><ul><li>Foremost concern </li></ul></ul><ul><li>Maintain an open airway with suctioning as needed </li></ul><ul><ul><li>Primary nursing responsibility </li></ul></ul><ul><li>Limit the effects of immobility such as skin care, ROM, turning and positioning schedule </li></ul><ul><li>Note effect of position changes on ICP and space activities as necessary. </li></ul><ul><li>Reorient pt to time, place and person as needed. </li></ul><ul><li>Keep familiar objects or pictures around the pt </li></ul><ul><li>Allow visitation of significant others </li></ul><ul><li>Establish alternate means of communication if unable to maintain verbal contact (pt who needs intubation) </li></ul>
    179. 187. Brain Abscess
    180. 188. CNS ABSCESSES <ul><li>Focal pyogenic infections of the central nervous system </li></ul><ul><li>Exert their effects mainly by: </li></ul><ul><ul><li>Direct involvement & destruction of the brain or spinal cord </li></ul></ul><ul><ul><li>Compression of parenchyma </li></ul></ul><ul><ul><li>Elevation of intracranial pressure </li></ul></ul><ul><ul><li>Interfering with blood &/or CSF flow </li></ul></ul><ul><li>Include: Brain abscess, subdural empyema, intracranial epidural abscess, spinal epidural abscess, spinal cord abscess </li></ul>
    181. 189. PATHOPHYSIOLOGY <ul><li>Begins as localized cerebritis (1-2 wks) </li></ul><ul><li>Evolves into a collection of pus surrounded by a well-vascularized capsule (3-4 wks) </li></ul><ul><li>Lesion evolution: </li></ul><ul><ul><li>Days 1-3: “early cerebritis stage” </li></ul></ul><ul><ul><li>Days 4-9: “late cerebritis stage” </li></ul></ul><ul><ul><li>Days 10-14: “early capsule stage” </li></ul></ul><ul><ul><li>> day14: “late capsule stage” </li></ul></ul>
    182. 190. PATHOGENESIS Etiologies: <ul><li>Direct spread from contiguous foci (40-50%) </li></ul><ul><li>Hematogenous (25-35%) </li></ul><ul><li>Penetrating trauma/surgery (10%) </li></ul><ul><li>Cryptogenic (15-20%) </li></ul>
    183. 191. DIRECT SPREAD (from contiguous foci) <ul><li>Occurs by: </li></ul><ul><ul><li>Direct extension through infected bone </li></ul></ul><ul><ul><li>Spread through emissary veins, diploic veins, local lymphatics </li></ul></ul><ul><li>The contiguous foci include : </li></ul><ul><ul><ul><li>Otitis media/mastoiditis </li></ul></ul></ul><ul><ul><ul><li>Sinusitis </li></ul></ul></ul><ul><ul><ul><li>Dental infection (<10%), typically with molar infections </li></ul></ul></ul><ul><ul><ul><li>Meningitis rarely complicated by brain abscess (more common in neonates with Citrobacter diversus meningitis, of whom 70% develop brain abscess) </li></ul></ul></ul>
    184. 192. HEMATOGENOUS SPREAD (from remote foci) <ul><li>Sources: </li></ul><ul><ul><li>Empyema, lung abscess, bronchiectasis, endocarditis, wound infections, pelvic infections, intra-abdominal source, etc… </li></ul></ul><ul><ul><li>may be facilitated by cyanotic HD, AVM. </li></ul></ul><ul><li>Results in brain abscess(es) at middle cerebral artery distribution </li></ul><ul><li>Often multiple </li></ul>
    185. 193. CLINICAL MANIFESTATIONS <ul><li>Non-specific symptoms </li></ul><ul><li>Mainly due to the presence of a space-occupying lesion </li></ul><ul><ul><ul><li>N/V, lethargy, focal neuro signs , seizures </li></ul></ul></ul><ul><li>Signs/symptoms influenced by </li></ul><ul><ul><ul><li>Location </li></ul></ul></ul><ul><ul><ul><li>Size </li></ul></ul></ul><ul><ul><ul><li>Virulence of organism </li></ul></ul></ul><ul><ul><ul><li>Presence of underlying condition </li></ul></ul></ul>
    186. 194. CLINICAL MANIFESTATIONS <ul><ul><ul><li>Headache </li></ul></ul></ul><ul><ul><ul><li>Often dull, poorly localized, non-specific </li></ul></ul></ul><ul><ul><ul><ul><li>Abrupt, extremely severe H/A </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Sudden worsening H/A with rupture of brain abscess into ventricle (often fatal) </li></ul></ul></ul></ul>
    187. 195. LOCATION & CLINICAL FEATURES <ul><li>FRONTAL LOBE : H/A, drowsiness, inattention, hemiparesis, motor speech disorder </li></ul><ul><li>TEMPORAL LOBE : Ipsilateral H/A, aphasia, visual field defect </li></ul><ul><li>PARIETAL LOBE : H/A, visual field defects, endocrine disturbances </li></ul><ul><li>CEREBELLUM : Nystagmus, ataxia, vomiting, dysmetria </li></ul>
    188. 196. DIAGNOSIS <ul><li>High index of suspicion </li></ul><ul><li>Contrast CT or MRI </li></ul><ul><li>Drainage/biopsy </li></ul>
    189. 197. IMAGING STUDIES <ul><li>MRI </li></ul><ul><ul><li>more sensitive for early cerebritis, satellite lesions, necrosis, ring, edema, especially posterior fossa & brain stem </li></ul></ul><ul><li>CT scan </li></ul><ul><li>99m Tc brain scan </li></ul><ul><ul><li>very sensitive; useful where CT or MRI not available </li></ul></ul><ul><li>Skull x-ray : insensitive, </li></ul><ul><ul><li>if air seen, consider possibility of brain abscess </li></ul></ul>
    190. 198. <ul><li>LABORATORY TESTS </li></ul><ul><li>BRAIN ABSCESS </li></ul><ul><li>Aspirate: Gram/AFB/fungal stains & cultures, cytopathology (+/-PCR for TB) </li></ul><ul><li>WBC Normal in 40% ( only moderate leukocytosis in ~ 50% </li></ul><ul><ul><ul><li>& only 10% have WBC >20,000) </li></ul></ul></ul><ul><li>ESR Usually moderately elevated </li></ul><ul><li>LP Contraindicated in patients with known/suspected brain abscess </li></ul><ul><ul><ul><ul><ul><li>Risk of herniation 15-30% </li></ul></ul></ul></ul></ul><ul><ul><ul><li>If done, m ay have normal CSF findings, but: </li></ul></ul></ul><ul><li>Usually elevated CSF protein & cell count (lymphs) </li></ul><ul><ul><li>Unremarkable glucose & CSF cultures rarely positive </li></ul></ul>
    191. 199. TREATMENT <ul><li>Combined medical & surgical </li></ul><ul><ul><ul><li>Aspiration or excision </li></ul></ul></ul><ul><ul><ul><li>empirical abx </li></ul></ul></ul><ul><li>Empirical antibiotics are selected based on: </li></ul><ul><ul><ul><li>Likely pathogen (consider primary source, underlying condition, & geography) </li></ul></ul></ul><ul><li>Modify abx based on stains </li></ul><ul><li>Duration: usually 6-8 wks </li></ul><ul><ul><ul><li>after surgical excision, a shorter course may suffice </li></ul></ul></ul>
    192. 200. Guillain-Barré – Polyneuritis – Acute Idiopathic Polyneuritis
    193. 201. Guillain-Barré – Polyneuritis <ul><li>An uncommon, acute, rapidly progressing and potentially fatal polyneuritis </li></ul><ul><li>The immune system destroys the myelin sheath </li></ul><ul><li>Exact etiology: </li></ul><ul><ul><li>unknown </li></ul></ul><ul><ul><li>research suggest cell-mediated immunologic reaction </li></ul></ul><ul><li>Often associated with: </li></ul><ul><ul><li>history of acute respiratory or GI illness </li></ul></ul><ul><ul><li>Surgery </li></ul></ul><ul><ul><li>Trauma </li></ul></ul><ul><ul><li>immunization 1-8 weeks before the onset of the disorder </li></ul></ul><ul><li>Women between 30-50 years are more susceptible </li></ul><ul><li>Respiratory failure is serious complication </li></ul>
    194. 202. Manifestations: <ul><ul><li>Symmetrical ascending weakness of the lower extremities </li></ul></ul><ul><ul><li>Paresthesia </li></ul></ul><ul><ul><li>Paralysis </li></ul></ul><ul><ul><li>Decrease in muscle tone </li></ul></ul><ul><ul><li>Decrease or absent deep tendon reflexes </li></ul></ul><ul><ul><li>Hypertension </li></ul></ul><ul><ul><li>Bradycardia </li></ul></ul><ul><ul><li>Orthostatic hypotension </li></ul></ul><ul><ul><li>Absent bowel and bladder function </li></ul></ul><ul><ul><li>Facial weakness </li></ul></ul><ul><ul><li>Dysphagia </li></ul></ul><ul><ul><li>Extraocular eye movements </li></ul></ul><ul><ul><li>Pain – generally worse at night </li></ul></ul><ul><ul><li>Difficulty communicating </li></ul></ul>
    195. 203. <ul><li>Diagnostic Tests </li></ul><ul><ul><li>Complete history and physical exam </li></ul></ul><ul><ul><li>CSF analysis </li></ul></ul><ul><ul><li>Electromyography (EMG) </li></ul></ul><ul><ul><li>Nerve conduction studies </li></ul></ul><ul><ul><li>Respiratory function studies </li></ul></ul>
    196. 204. Nursing Interventions: <ul><li>Promote optimal airway exchange </li></ul><ul><li>Monitor arterial blood gases </li></ul><ul><li>Maintain emergency intubation equipment at the bedside </li></ul><ul><li>Provide oxygen, suctioning and chest physiotherapy as needed. </li></ul><ul><li>Monitor the client for dysphagia and implement dysphagia interventions as appropriate. </li></ul><ul><li>Administer prescribed analgesics </li></ul><ul><li>Implement communication interventions </li></ul><ul><li>Provide emotional support </li></ul><ul><li>Prevent complications of physical immobility </li></ul><ul><li>Assist with plasmapheresis as appropriate. </li></ul>
    197. 205. Guillain-Barré - Polyneuritis <ul><li>Peripheral nerve disease </li></ul><ul><li>Prior infection; autoimmune response </li></ul><ul><li>Weakness and paralysis, begins in extremities and works up </li></ul><ul><li>Respiratory failure may occur </li></ul>
    198. 206. Rabies
    199. 207. RABIES 2 kinds: Etiology: A.K.A.: Vital facts: Hydrophobia, Lyssa Rabies virus (A rhabdovirus of the genus lyssavirus) Urban/ Canine rabies and Sylvatic rabies Urban/ Canine Rabies: Transmitted by dogs Sylvatic Rabies: Transmitted by bats Didn’t you know? The Philippines has one of the highest prevalence rates of rabies in the world
    200. 208. RABIES Is man to man transmission possible? Can it be introduced thru breaks in the skin? MOT: Vital facts: Bite from a rabid animal Very rare Yes How about organ transplants? Yes. (Corneal transplant) Incubation period: R-a-b-i-e-s (6 weeks/ 2-8 weeks) Communicability period: 3 days before onset until the whole disease duration
    201. 209. RABIES CNS Sx (Site of bite): CNS Sx (early): Hydrophobia: Signs and symptoms: Spasms of muscles of deglutition Headache, apprehension, fever Sensory changes CNS Sx (late): Paralysis, delirium, convulsions Usual lifespan of victim w/o medical intervention: 2-6 days Usual cause of death: Respiratory paralysis
    202. 210. RABIES If it dies or shows signs of rabies, behead it and bring to doctor Submit for immunization while waiting for results If dog is not available: submit for immunization Observe the dog for 14 days, do not kill it yet. Patient may be given antibiotics/ tetanus immune globulin Wash the wound with antiseptics/ soap & water Management: Sequence of actions
    203. 211. RABIES Responsible pet ownership: Immunization of pets after 3 months of age and yearly thereafter Never allow pets to roam the streets Take good care of pets: bathe, feed, clean sleeping quarters Your pet’s action is your responsibility
    204. 212. Rabies <ul><li>Rhabovirus infection of CNS transmitted by infected saliva that enters the body through bite or open wound </li></ul><ul><li>Critical illness almost always fatal </li></ul><ul><li>Source = bite of infected domestic or wild animal </li></ul><ul><li>Incubation is 10 days to years </li></ul>
    205. 213. Manifestations occur in stages: <ul><li>Prodromal: </li></ul><ul><li>wound is painful </li></ul><ul><li>various paresthesias </li></ul><ul><li>general signs of infection </li></ul><ul><li>increased sensitivity to light, sound, </li></ul><ul><li>skin temperature changes </li></ul><ul><li>Excitement stage: </li></ul><ul><li>periods of excitement and quiet </li></ul><ul><li>develops laryngospasm </li></ul><ul><li>afraid to drink (hydrophobia) </li></ul><ul><li>Convulsions </li></ul><ul><li>muscle spasms and </li></ul><ul><li>death usually due to respiratory failure </li></ul>
    206. 214. Rabies <ul><li>Collaborative Care </li></ul><ul><li>Animal that bit person is held under observation for 7 – 10 days to detect rabies </li></ul><ul><li>Sick animal are killed and their brains are tests for presence of rabies virus </li></ul><ul><li>Blood of client may be tested for rabies antibodies </li></ul>
    207. 215. Rabies <ul><li>Post-exposure treatment </li></ul><ul><li>Rabies immune globulin (RIG) is administered for passive immunization </li></ul><ul><li>Client often has local and mild systemic reaction; treatment is over 30 days </li></ul><ul><li>Treatment of client with rabies: </li></ul><ul><li>involves intensive care treatment </li></ul>
    208. 216. <ul><li>Health Promotion </li></ul><ul><li>Vaccination of pets </li></ul><ul><li>Avoid wild animals, especially those appearing ill </li></ul><ul><li>Follow up care for any bites </li></ul>Rabies
    209. 217. Tetanus (lockjaw)
    210. 218. Tetanus (lockjaw) <ul><li>Disorder of nervous system caused by neurotoxin </li></ul><ul><li>Etiology: </li></ul><ul><ul><li>Clostridium tetani , anaerobic bacillus present in the soil </li></ul></ul><ul><li>Contract disease from: </li></ul><ul><ul><li>open wound contaminated with dirt, debris </li></ul></ul><ul><ul><li>Traumatic wound like gunshot </li></ul></ul><ul><ul><li>Compound fracture </li></ul></ul><ul><ul><li>Dental infection, animal bite </li></ul></ul><ul><ul><li>Dirty/contaminated needles during illegal drug use </li></ul></ul><ul><li>Has high mortality rate </li></ul><ul><li>Incubation period range from 7-21days, ave 7 days </li></ul>
    211. 219. <ul><li>tetanus is generalized, affecting skeletal muscles throughout the body. </li></ul><ul><li>However, tetanus is sometimes localized to muscles near an entry wound. </li></ul>Tetanus (lockjaw)
    212. 220. Pathophysiology <ul><li>Manifestations of tetanus are caused by an exotoxin (tetanospasmin). </li></ul><ul><li>The toxin may enter the CNS along the peripheral motor nerves or may be bloodborne to nervous tissue. </li></ul><ul><li>Tetanospasmin binds irreversibly to the ganglioside membranes of nerve synapses, blocking release of inhibitory transmitter from nerve terminals and thereby causing a generalized tonic spasticity, usually with superimposed intermittent tonic seizures. </li></ul><ul><li>Disinhibition of autonomic neurons and loss of control of adrenal catecholamine release cause autonomic instability and a hypersympathetic state. Once bound, the toxin cannot be neutralized. </li></ul>
    213. 221. Manifestations <ul><li>hypertonic muscle contraction </li></ul><ul><li>Stiffness of jaw </li></ul><ul><li>Stiff neck </li></ul><ul><li>Opisthotonos (severe arching of the back) </li></ul><ul><li>Retraction of the head </li></ul><ul><li>Laryngeal or respiratory spasms </li></ul><ul><li>Diaphoresis </li></ul><ul><li>Tachycardia </li></ul><ul><li>Dysphagia </li></ul><ul><li>Spasms of jaw and facial muscles </li></ul><ul><li>Develops generalized seizures </li></ul><ul><li>painful body muscle spasms </li></ul><ul><li>Late stage: </li></ul><ul><ul><li>Difficulty opening the jaw (trismus) </li></ul></ul><ul><ul><li>Fluctuation of heart rate and BP </li></ul></ul><ul><li>Death occurs from respiratory and cardiac complications </li></ul>
    214. 222. <ul><li>Risus Sardonicus </li></ul><ul><ul><li>Facial muscle spasm produces a characteristic expression with a fixed smile and elevated eyebrows </li></ul></ul><ul><li>Distinguishing signs: </li></ul><ul><ul><li>intact sensorium </li></ul></ul><ul><ul><li>normal CSF, and </li></ul></ul><ul><ul><li>muscle spasms </li></ul></ul>
    215. 223. Opisthotonus
    216. 224. Tetanus neonatorum: <ul><li>Tetanus in neonates is usually generalized and frequently fatal. </li></ul><ul><li>It often begins in inadequately cleansed umbilical stumps in children born of inadequately immunized mothers. </li></ul><ul><li>Onset during the first 2 wk of life is characterized by rigidity, spasms, and poor feeding. Bilateral deafness may occur in surviving children. </li></ul>
    217. 225. Tetanus (lockjaw) <ul><li>Diagnosis is made on clinical manifestations </li></ul><ul><li>Treatment: </li></ul><ul><ul><li>Antibiotics (doxycycline, metronidazole, penicillin G) </li></ul></ul><ul><ul><li>Chlorpromazine (Thorazine) </li></ul></ul><ul><ul><li>Diazepam (Valium ) for muscles spasms, seizure </li></ul></ul><ul><ul><li>Benzodiazepines to control rigidity and spasm. </li></ul></ul>
    218. 226. 3 Guiding Principles for treatment: <ul><li>Prevent further toxin release by debriding the wound and giving an antibiotic (see below); </li></ul><ul><li>Neutralize toxin outside the CNS with human tetanus immune globulin and tetanus toxoid, taking care to inject into different body sites and thus avoid neutralizing the antitoxin; and </li></ul><ul><li>Minimize the effect of toxin already in the CNS. </li></ul>
    219. 227. Health Promotion <ul><li>Active immunization with boosters given at time of exposure </li></ul><ul><li>Passive immunization is given to persons who are not adequately immunized </li></ul>
    220. 228. Nursing Interventions: <ul><li>Monitor CBC, serum electrolytes, arterial blood gases, glucose, clotting factors and albumin </li></ul><ul><li>Place the client in a dark, quiet room away from noise </li></ul><ul><li>Administer prescribed sedation </li></ul><ul><li>Avoid unnecessary touching of the client </li></ul><ul><li>When touching the client is necessary, use a firm touch </li></ul><ul><li>Maintain a warmer than normal temperature </li></ul><ul><li>Avoid covering the client with bed linens </li></ul><ul><li>Priority is to ensure tetanus prophylaxis by antitoxin </li></ul><ul><li>Wash the wound with warm soapy water to decrease incidence of tetanus </li></ul>
    221. 229. Supportive care: <ul><li>Intubation (moderate/severe cases) </li></ul><ul><li>Mechanical ventilation is essential when neuromuscular blockade is required to control muscle spasms that impair respirations. </li></ul><ul><li>Stool softener (constipation) </li></ul><ul><li>A rectal tube may control distention. </li></ul><ul><li>Bladder catheterization is required if urinary retention occurs. </li></ul><ul><li>Chest physiotherapy, </li></ul><ul><li>frequent turning, and forced coughing are essential to prevent pneumonia. </li></ul><ul><li>Analgesia with opioids is often needed. </li></ul>
    222. 230. Botulism
    223. 231. Botulism <ul><li>Food poisoning caused by ingestion of food contaminated with toxin </li></ul><ul><li>Etiology: </li></ul><ul><ul><li>Clostridium botulinum , anaerobic bacteria found in soil </li></ul></ul><ul><li>Contracted by eating contaminated foods usually improperly canned or cooked </li></ul><ul><li>Incubation period: 18-36 hrs </li></ul><ul><li>Untreated death rate is high </li></ul>
    224. 232. Pathophysiology: <ul><li>Bacteria produce a toxin, which blocks release of acetylcholine from nerve endings causing respiratory failure by paralysis of muscles </li></ul>
    225. 233. Botulism <ul><li>Manifestations: </li></ul><ul><li>Visual disturbances </li></ul><ul><ul><li>diplopia </li></ul></ul><ul><li>Gastrointestinal symptoms </li></ul><ul><ul><li>Dysphagia </li></ul></ul><ul><ul><li>Paralytic ileus </li></ul></ul><ul><ul><li>Constipation </li></ul></ul><ul><ul><li>Abdominal pain </li></ul></ul><ul><li>Paralysis of all muscle groups </li></ul><ul><ul><li>Dysarthria </li></ul></ul><ul><ul><li>Weakness </li></ul></ul><ul><li>Respiratory failure </li></ul>
    226. 234. <ul><li>Diagnosis </li></ul><ul><li>Complete pt history </li></ul><ul><li>Stool culture for Clostridium botulinum </li></ul><ul><li>CBC </li></ul><ul><li>Testing the suspected food </li></ul>
    227. 235. Botulism <ul><li>Treatment </li></ul><ul><li>Administration of antitoxin </li></ul><ul><li>Supportive treatment including mechanical ventilation and systemic support in intensive care unit </li></ul>
    228. 236. Nursing Interventions: <ul><li>Administer prescribed botulism antitoxin after the client is tested for hypersensitivity and immediately after the diagnosis is made. </li></ul><ul><li>Lavage the stomach or administer laxatives </li></ul><ul><li>Monitor the client for respiratory paralysis </li></ul><ul><li>Implement tracheostomy and mechanical ventilation interventions as appropriate </li></ul><ul><li>Report the disorder to CDC </li></ul><ul><li>Primary prevention should be the goal </li></ul>
    229. 237. <ul><li>Instruct clients on proper canning of home foods, particularly those wuth a low-acid content. </li></ul><ul><ul><li>Boil foods for 10 minutes </li></ul></ul><ul><ul><li>Remove bad spots from all fruits and vegetables before canning </li></ul></ul><ul><ul><li>Ensure canning jar is airtight </li></ul></ul><ul><ul><li>Store canned foods in a cool location </li></ul></ul><ul><ul><li>Discard ant canned container that swells or looks bad when opened. </li></ul></ul>Nursing Interventions:
    230. 238. CVA
    231. 239. CEREBROVASCULAR ACCIDENTS <ul><li>An umbrella term that refers to any functional abnormality of the CNS related to disrupted blood supply </li></ul>
    232. 240. CEREBROVASCULAR ACCIDENTS <ul><li>Can be divided into two major categories </li></ul><ul><li>1. Ischemic stroke- </li></ul><ul><ul><li>Caused </li></ul></ul><ul><ul><ul><li>Thrombus – associated with atherosclerosis </li></ul></ul></ul><ul><ul><ul><li>Embolus – breaking off and travels to the cerebral/carotid arteries </li></ul></ul></ul><ul><li>2. Hemorrhagic stroke </li></ul><ul><ul><li>caused commonly by hypertensive bleeding </li></ul></ul>
    233. 241. <ul><li>Transient ischemic attack (TIA)/ </li></ul><ul><ul><li>Referred as “silent stroke” </li></ul></ul><ul><ul><li>Temporary loss of neurological function often lasting less than 15 minutes and no more than 24 hrs </li></ul></ul><ul><li>Reversible ischemic neurological deficit (RIND) </li></ul><ul><ul><li>Temporary loss of neurological function lasting more than 24 hrs but less than 1 week </li></ul></ul><ul><ul><li>Indications of progressing cerebrovascular disease </li></ul></ul>
    234. 244. CEREBROVASCULAR ACCIDENTS <ul><li>The stroke continuum </li></ul><ul><li>1. TIA- transient ischemic attack, temporary neurologic loss less than 24 hours duration </li></ul><ul><li>2. Reversible Neurologic deficits </li></ul><ul><li>3. Stroke in evolution </li></ul><ul><li>4. Completed stroke </li></ul>
    235. 245. General manifestations
    236. 246. CEREBROVASCULAR ACCIDENTS: Ischemic Stroke <ul><li>There is disruption of the cerebral blood flow due to obstruction by embolus or thrombus </li></ul>
    237. 247. RISKS FACTORS <ul><li>Non-modifiable </li></ul><ul><li>Advanced age </li></ul><ul><li>Gender </li></ul><ul><li>Race </li></ul><ul><li>Modifiable </li></ul><ul><li>Hypertension </li></ul><ul><li>Cardio disease </li></ul><ul><li>Obesity </li></ul><ul><li>Smoking </li></ul><ul><li>Diabetes mellitus </li></ul><ul><li>Hypercholesterolemia </li></ul><ul><li>Atrial fibrillation </li></ul>
    238. 248. Pathophysiology of ischemic stroke <ul><li>Disruption of blood supply </li></ul><ul><li>Anaerobic metabolism ensues </li></ul><ul><li>Decreased ATP production leads to impaired membrane function </li></ul><ul><li>Cellular injury and death can occur </li></ul>
    239. 249. CEREBROVASCULAR ACCIDENTS: Ischemic Stroke <ul><li>CLINICAL MANIFESTATIONS </li></ul><ul><li>1. Numbness or weakness </li></ul><ul><li>2. Confusion or change of LOC </li></ul><ul><li>3. Motor and speech difficulties </li></ul><ul><li>4. Visual disturbance </li></ul><ul><li>5. Severe headache </li></ul>
    240. 250. CEREBROVASCULAR ACCIDENTS: Ischemic Stroke <ul><li>Motor Loss </li></ul><ul><li>Hemiplegia - one-sided paralysis </li></ul><ul><li>Hemiparesis - weakness </li></ul><ul><li>Neglect - unaware of weakness on one side of the body </li></ul><ul><li>Ptosis – drooping of eyelid </li></ul>
    241. 251. CEREBROVASCULAR ACCIDENTS: Ischemic Stroke <ul><li>Communication loss </li></ul><ul><li>Dysarthria= difficulty in speaking </li></ul><ul><li>Aphasia= Loss of speech </li></ul><ul><ul><li>Expressive =difficulty in ability to write/speak </li></ul></ul><ul><ul><li>Receptive = difficulty with verbalization of sounds & words </li></ul></ul><ul><ul><li>Global = impairment of all verbal and understanding of communication </li></ul></ul><ul><li>Apraxia= inability to perform a previously learned action </li></ul><ul><li>Alexia = difficulty reading </li></ul><ul><li>Agraphia = difficulty writing </li></ul><ul><li>Agnosia = inability to read, write or understand material </li></ul>
    242. 252. CEREBROVASCULAR ACCIDENTS: Ischemic Stroke <ul><li>Perceptual disturbances </li></ul><ul><li>Amaurosis fugax = temporary period of blindness in one eye </li></ul><ul><li>Hemianopsia – blindness in 1 side of the visual field </li></ul><ul><ul><li>Homonymous hemianopsia – loss of visual field on the nasal side and the opposite temporal side due to damage of the optic nerve </li></ul></ul><ul><li>Sensory loss </li></ul><ul><li>Paresthesia (numbness) </li></ul>
    243. 253. Medications <ul><li>Diuretic drugs </li></ul><ul><ul><li>Mannitol and furosemide to decrease cerebral edema </li></ul></ul><ul><li>Anticoagulant </li></ul><ul><ul><li>Heparin and warfarin (Coumadin) </li></ul></ul><ul><li>Platelet inhibitors – prevent thromboembolic </li></ul><ul><ul><li>Ticlopidine (Ticlid), clopidogrel (Plavix) dipyridamole (Persantine) </li></ul></ul>
    244. 254. CEREBROVASCULAR ACCIDENTS: Ischemic Stroke <ul><li>DIAGNOSTIC test </li></ul><ul><li>1. CT scan </li></ul><ul><li>2. MRI </li></ul><ul><li>3. Angiography </li></ul>
    245. 255. CEREBROVASCULAR ACCIDENTS: Ischemic Stroke <ul><li>NURSING INTERVENTIONS </li></ul><ul><li>Improve Mobility and prevent joint deformities </li></ul><ul><li>Correctly position patient to prevent contractures </li></ul><ul><ul><li>Place pillow under axilla </li></ul></ul><ul><ul><li>Hand is placed in slight supination- “C” </li></ul></ul><ul><ul><li>Change position every 2 hours </li></ul></ul><ul><ul><li>Arm sling to prevent shoulder subluxation </li></ul></ul>
    246. 256. CEREBROVASCULAR ACCIDENTS: Ischemic Stroke <ul><li>NURSING INTERVENTIONS </li></ul><ul><li>2. Enhance self-care </li></ul><ul><li>Carry out activities on the unaffected side </li></ul><ul><li>Prevent unilateral neglect </li></ul><ul><li>Keep environment organized </li></ul><ul><li>Use large mirror </li></ul>
    247. 257. CEREBROVASCULAR ACCIDENTS: Ischemic Stroke <ul><li>NURSING INTERVENTIONS </li></ul><ul><li>3. Manage sensory-perceptual difficulties </li></ul><ul><li>Approach patient on the Unaffected side </li></ul><ul><li>Encourage to turn the head to the affected side to compensate for visual loss </li></ul>
    248. 258. CEREBROVASCULAR ACCIDENTS: Ischemic Stroke <ul><li>NURSING INTERVENTIONS </li></ul><ul><li>4. Manage dysphagia </li></ul><ul><li>Place food on the UNAFFECTED side </li></ul><ul><li>Provide smaller bolus of food </li></ul><ul><li>Manage tube feedings if prescribed </li></ul><ul><li>Thickened liquid – to prevent aspiration during stroke evolution </li></ul><ul><li>Before feeding, check for presence of gag reflex </li></ul>
    249. 259. CEREBROVASCULAR ACCIDENTS: Ischemic Stroke <ul><li>NURSING INTERVENTIONS </li></ul><ul><li>5. Help patient attain bowel and bladder control </li></ul><ul><li>Intermittent catheterization is done in the acute stage </li></ul><ul><li>Offer bedpan on a regular schedule </li></ul><ul><li>High fiber diet and prescribed fluid intake </li></ul>
    250. 260. CEREBROVASCULAR ACCIDENTS: Ischemic Stroke <ul><li>NURSING INTERVENTIONS </li></ul><ul><li>6. Improve thought processes </li></ul><ul><li>Support patient and capitalize on the remaining strengths </li></ul>
    251. 261. CEREBROVASCULAR ACCIDENTS: Ischemic Stroke <ul><li>NURSING INTERVENTIONS </li></ul><ul><li>7. Improve communication </li></ul><ul><li>Anticipate the needs of the patient </li></ul><ul><li>Offer support </li></ul><ul><li>Provide time to complete the sentence </li></ul><ul><li>Provide a written copy of scheduled activities </li></ul><ul><li>Use of communication board </li></ul><ul><li>Give one instruction at a time </li></ul>
    252. 262. CEREBROVASCULAR ACCIDENTS: Ischemic Stroke <ul><li>NURSING INTERVENTIONS </li></ul><ul><li>8. Maintain skin integrity </li></ul><ul><li>Use of specialty bed </li></ul><ul><li>Regular turning and positioning </li></ul><ul><li>Keep skin dry and massage NON-reddened areas </li></ul><ul><li>Provide adequate nutrition </li></ul>
    253. 263. CEREBROVASCULAR ACCIDENTS: Ischemic Stroke <ul><li>NURSING INTERVENTIONS </li></ul><ul><li>9. Promote continuing care </li></ul><ul><li>Referral to other health care providers </li></ul>
    254. 264. CEREBROVASCULAR ACCIDENTS: Ischemic Stroke <ul><li>NURSING INTERVENTIONS </li></ul><ul><li>10. Improve family coping </li></ul><ul><li>11. Help patient cope with sexual dysfunction </li></ul>
    255. 265. CVA: Hemorrhagic Stroke <ul><li>Normal brain metabolism is impaired by interruption of blood supply, compression and increased ICP </li></ul><ul><li>Interruption of vessel wall integrity accounting for a bleed into the brain tissues as a result of: </li></ul><ul><ul><li>Hypertension </li></ul></ul><ul><ul><li>Aneurysm (weakening or ballooning of an artery) </li></ul></ul><ul><ul><li>Subarachnoid hemorrhage </li></ul></ul><ul><ul><li>Arteriovenous malformation (embryonic abnormality resulting in a conglomeration of spaghetti-like tangles and thin walled dilated vessels prone to rupture) </li></ul></ul>
    256. 266. CVA: Hemorrhagic Stroke <ul><li>Sudden and severe headache </li></ul><ul><li>Same neurologic deficits as ischemic stroke </li></ul><ul><li>Loss of consciousness </li></ul><ul><li>Meningeal irritation </li></ul><ul><li>Visual disturbances </li></ul>
    257. 267. CVA: Hemorrhagic Stroke <ul><li>DIAGNOSTIC TESTS </li></ul><ul><li>1. CT scan </li></ul><ul><li>2. MRI </li></ul><ul><li>3. Lumbar puncture (only if with no increased ICP) </li></ul>
    258. 268. CVA: Hemorrha