Seizure Ppt Etc

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Seizure Ppt Etc

  1. 1. S E I Z U R E Dr. Anthony P. Toledo MSNET2 D I S O R D E R
  2. 2. DEFINITION Involuntary muscle contractions caused by abnormal discharged of electrical impulses from nerve cells Seizure
  3. 3. CLASSIFICATION <ul><li>Generalized absence (petit mal) </li></ul><ul><li>Generalized tonic-clonic (grand mal) </li></ul><ul><li>Myolonic </li></ul><ul><li>Atonic </li></ul><ul><li>Generalized seizures </li></ul><ul><li>Partial seizures (focal seizures) </li></ul><ul><li>Simple partial </li></ul><ul><li>Complex partial </li></ul>Seizure
  4. 4. Seizure CLASSIFICATION <ul><li>Partial seizures (focal seizures) </li></ul>
  5. 5. Seizure CLASSIFICATION <ul><li>Generalized seizures </li></ul>
  6. 6. CLASSIFICATION <ul><li>Unclassified seizures </li></ul>Seizure TYPE DESCRIPTION SIGNS AND SYMPTOMS GENERALIZED ABSENCE (petit mal) - Sudden onset; - Lasts 5 to 10 seconds; - Can have 100 daily; - Precipitated by stress; - Hyperventilation; - Hypoglycemia; - Fatigue; - Differentiated from day dreaming - Loss of responsiveness, but continued ability to maintain posture control and not fall; - Twitching eyelids; - Lip smacking; - No postictal symptoms MYOCLONIC - Movement disorder(not a seizure); - Seen as child awakens or falls asleep; - May be precipitated by touch or visual stimuli; - Focal or generalized; - Symmetrical or asymmetrical - No loss of consciousness; - Sudden; - Brief; - Shocklike involuntary contraction of one muscle group
  7. 7. Seizure CLASSIFICATION <ul><li>Unclassified seizures (cont’d) </li></ul>
  8. 8. CLASSIFICATION <ul><li>Unclassified seizures (cont’d) </li></ul>Seizure TYPE DESCRIPTION SIGNS AND SYMPTOMS GENERALIZED CLONIC - Opposing muscles contract and relax alternately in rhythmic pattern; - May occur in one limb more than others - Mucus production TONIC Muscles are maintained in continuous contracted state (rigid posture) - Variable loss of consciousness; - Pupils dilate; - Eyes roll up; - Glottis closes; - Possible incontinence; - May foam at mouth TONIC-CLONIC (grand mal, major motor) Violent total body seizure - Aura; - Tonic first(20 – 40 seconds); - Clonic next; - Postictal symptoms
  9. 9. Seizure CLASSIFICATION <ul><li>Unclassified seizures (cont’d) </li></ul>
  10. 10. CLASSIFICATION <ul><li>Unclassified seizures (cont’d) </li></ul>Seizure TYPE DESCRIPTION SIGNS AND SYMPTOMS GENERALIZED ATONIC Drop and fall attack; Needs to wear protected helmet Loss of posture tone AKINETIC Sudden brief loss of muscle tone or posture Temporary loss of consciousness
  11. 11. CLASSIFICATION <ul><li>Unclassified seizures (cont’d) </li></ul>Seizure TYPE DESCRIPTION SIGNS AND SYMPTOMS PARTIAL SIMPLE PARTIAL Symptoms confined to one hemisphere - May have motor (change in posture), - Sensory (hallucinations); - Autonomic (flushing, tachycardia) symptoms; - No loss of consciousness COMPLEX PARTIAL Begins in one focal area, but spreads to both hemispheres (more common in adult) - Loss of consciousness; - Aura of visual disturbances; - Postictal symptoms
  12. 12. CLASSIFICATION <ul><li>Unclassified seizures (cont’d) </li></ul>Seizure TYPE DESCRIPTION SIGNS AND SYMPTOMS UNCLASSIFIED FEBRILE - Seizure threshold lowered by elevated temperature; - Only one seizure per fever; - Common in 4% of population under age 5; - Occurs when temperature is rapidly rising -Lasts less than 5 minutes; - Generalized; - Transient and nonprogressive; - Doesn’t generally result in brain damage; - EEG is normal after 2 weeks STATUS EPILEPTICUS Prolonged and frequent repetition of seizures without interruption; results in anoxia and cardiac and respiratory arrest - Consciousness not regained between seizures; - Lasts more than 30 minutes
  13. 13. CAUSES <ul><li>Idiopathic origin </li></ul><ul><li>Head injury </li></ul><ul><li>Hypoglycemia </li></ul><ul><li>Brain tumor </li></ul><ul><li>Infection </li></ul><ul><li>Anoxia </li></ul><ul><li>Cerebrovascular disease – leading cause of seizure in elderly </li></ul>Seizure
  14. 14. Seizure PATHOPHYSIOLOGY <ul><li>Many neurons fire in a synchronous pattern, resulting in a transient physiologic disturbance </li></ul><ul><li>Physiologic disturbances include abnormal movements, abnormal sensations and change in LOC </li></ul>
  15. 15. ASSESSMENT FINDINGS <ul><li>Aura </li></ul><ul><li>LOC </li></ul><ul><li>Dyspnea </li></ul><ul><li>Fixed and dilated pupil </li></ul><ul><li>Incontinence </li></ul>Seizure
  16. 16. DIAGNOSTIC TEST FINDINGS <ul><li>EEG : abnormal wave patterns, focus of seizure activity </li></ul><ul><li>CT scan : a space occupying lesion </li></ul><ul><li>MRI : pathologic changes </li></ul><ul><li>BRAIN MAPPING : identification of seizure areas </li></ul>Seizure
  17. 17. MEDICAL MANAGEMENT <ul><li>Diet: Ketogenic (a diet high in fats and proteins, and low in carbohydrates) </li></ul><ul><li>I.V. therapy: saline lock </li></ul><ul><li>Activity: bed rest </li></ul><ul><li>Monitoring: Vital signs, I/O, and neurovital signs </li></ul><ul><li>Laboratory studies: glucose, potassium, and anticonvulsant drug levels if applicable </li></ul><ul><li>Special care : seizure precautions </li></ul><ul><li>Anticonvulsants: phenytoin (Dilantin), ethosuximide (Zarontin), Phenobarbital (Luminal), Carbamazepine (Tegretol), valporic acid (Depakote), gabapentin (Neurontin), lamotrigine (Lamictal), topiramote (Topamax) </li></ul>Seizure
  18. 18. NURSING CARE DURING SEIZURE <ul><li>Provide privacy and protect the patient from curios on-lookers, </li></ul><ul><ul><li>Ease the patient to the floor, if possible </li></ul></ul><ul><ul><li>Protect the head with a pad to prevent injury (from striking a hard surface) </li></ul></ul><ul><ul><li>Loosen constrictive clothing </li></ul></ul><ul><ul><li>Push aside any furniture that may injure the patient during the seizure </li></ul></ul><ul><ul><li>If the patient is on bed, remove the pillows and raise side rails </li></ul></ul><ul><ul><li>If an aura precedes the seizure, insert an oral airway to reduce the possibility of the tongue or cheek being bitten </li></ul></ul>Seizure
  19. 19. NURSING CARE DURING SEIZURE (cont’d) <ul><li>Do not attempt to pry open jaws that are clenched in a spasm to insert anything. Broken teeth and injury to the lips and tongue may result from such an action </li></ul><ul><ul><li>No attempt should be made to restrain the patient during the seizure because muscular contractions are strong and restraint can produce injury </li></ul></ul><ul><ul><li>If possible, place the patient on one side with head flexed forward, which allows the tongue to fall forward and facilitates drainage of saliva and mucus. If suction is available, use it if necessary to clear secretions </li></ul></ul>Seizure
  20. 20. Seizure
  21. 21. Seizure <ul><li>A generalized tonic clonic seizure. Here the whole brain is affecting from the beginning. In: </li></ul><ul><li>there is a cry and loss of consciousness, arms flex up then extend in </li></ul><ul><li>and remain rigid (the tonic phase) for a few seconds. A series of jerking movements take place (the clonic phase) as muscles contract and relax together. In </li></ul><ul><li>the jerking is slowing down and will eventually stop. In </li></ul><ul><li>the man has been placed on his side to aid breathing and to keep the airway clear. </li></ul>
  22. 22. NURSING CARE AFTER THE SEIZURE <ul><li>Keep the patient on one side to prevent aspiration. Make sure the airway is patent </li></ul><ul><li>There is usually a period of confusion after a grand mal seizure </li></ul><ul><li>A short apneic period may occur during or immediately after a generalized seizure </li></ul><ul><li>The patient, on awakening, should be reoriented to the environment </li></ul><ul><li>If the patients becomes agitated after a seizure (postictal), use calm persuasion and gentle restraint </li></ul>Seizure
  23. 23. PATIENT EDUCATION <ul><li>Take medications at regular basis </li></ul><ul><li>Avoid alcohol. This 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>Lead an active life </li></ul>Seizure
  24. 24. E P I L E P T I C U S S T A T U S
  25. 25. DEFINITION Status Epilepticus <ul><li>Acute prolonged seizure activity </li></ul><ul><li>Is a series of generalized seizures that occur without full recovery of consciousness between attacks </li></ul><ul><li>Produces cumulative effects </li></ul><ul><li>Brain damage may occur secondary to prolonged hypoxia and exhaustion </li></ul><ul><li>The client is often in coma for 12 to 24 hours or longer, during which time recurring seizures occur </li></ul><ul><li>The attack is usually related to failure to take prescribed anticonvulsants </li></ul>
  26. 26. CAUSES Status Epilepticus <ul><li>Perinatal hypoxia or anoxia that injures the brain </li></ul><ul><li>Meningitis </li></ul><ul><li>Metabolic disorder </li></ul>In infants In adults <ul><li>Infections of the brain, </li></ul><ul><li>Strokes </li></ul><ul><li>Brain tumors </li></ul><ul><li>Severe head trauma </li></ul>
  27. 27. PATHOPHYSIOLOGY Status Epilepticus The exact pathophysiology of why seizure evolves into status is complex and not fully understood
  28. 28. DIAGNOSTIC FINDINGS Status Epilepticus <ul><li>EEG – to monitor response to treatment </li></ul><ul><li>BLOOD TEST – glucose, electrolytes, liver functions and illicit substances </li></ul>
  29. 29. MEDICAL MANAGEMENT Status Epilepticus GOAL <ul><li>to stop the seizure as quickly as possible </li></ul><ul><li>to ensure adequate cerebral oxygenation, </li></ul><ul><li>to maintain the patient in a seizure free state </li></ul>
  30. 30. MEDICAL MANAGEMENT (cont’d) Status Epilepticus <ul><li>cuffed endotracheal tube is inserted - - - if the patient remains unconscious and unresponsive </li></ul><ul><li>Intravenous diazepam (valium), lorazepam (ativan), or fosphynetoin (cerebyx) - - - is given slowly in an attempt to halt seizure immediately </li></ul><ul><li>Other medications (phynetoin, Phenobarbital) - - - given later to maintain a seizure free state </li></ul><ul><li>Blood samples are obtained - - - to monitor serum electrolytes, glucose, and phynetoin levels </li></ul><ul><li>EEG monitoring - - - useful in determining the nature of seizure activity </li></ul><ul><li>IV infusion of dextrose - - - given if the seizure is due to hypoglycemia </li></ul>
  31. 31. NURSING MANAGEMENT Status Epilepticus <ul><li>Initiates ongoing assessment and monitoring of respiratory and cardiac functioning </li></ul><ul><li>Monitoring and documenting the seizure activity and the patient’s responsiveness </li></ul><ul><li>The patient is turned to a side lying position to assist in draining pharyngeal secretions </li></ul><ul><li>The IV line must be closely monitored because it may be dislodged during seizure </li></ul>
  32. 32. RECOVERY AND REHABILITATION Status Epilepticus <ul><li>The recovery from status epilepticus will depend on its duration. If status can be effectively stopped in a relatively short period of time, complete neurological recovery is possible. </li></ul><ul><li>The longer the seizure persist, the greater the chance of cerebral injury </li></ul><ul><li>A complication of status epilepticus can actually be the development of epilepsy in a percentage cases. </li></ul>
  33. 33. E P I L E P S Y
  34. 34. DEFINITION Epilepsy <ul><li>Group of syndromes characterized by recurring seizures </li></ul><ul><li>Epileptic syndromes are classified by specific patterns of clinical features, including age of onset, family history and seizure type </li></ul><ul><li>Can be primary (idiopathic) or secondary (when the cause is known and the epilepsy is a symptom of another underlying condition such as brain tumor) </li></ul><ul><li>Can follow </li></ul><ul><ul><li>birth trauma, </li></ul></ul><ul><ul><li>asphysia neonatorum, </li></ul></ul><ul><ul><li>head injuries, </li></ul></ul><ul><ul><li>some infectious disease ( bacterial, viral, parasitic ) </li></ul></ul><ul><ul><li>toxicity ( carbon dioxide and lead poisoning ) </li></ul></ul><ul><ul><li>circulatory problems </li></ul></ul><ul><ul><li>fever, metabolic and nutritional disorder </li></ul></ul><ul><ul><li>drug or alcohol intoxication </li></ul></ul><ul><li>also associated with brain tumors, abscess, and congenital malformations </li></ul>
  35. 35. PATHOPHYSIOLOGY Epilepsy <ul><li>Messages from the body are carried by the neurons of the brain by means of discharges of electrochemical energy that sweep along them. </li></ul><ul><li>These impulses occur in burst whenever a nerve cell has a task to perform. </li></ul><ul><li>Sometimes, these cells or groups of cells continue firing after the task is finished </li></ul><ul><li>During the period of unwanted discharges, parts of the body controlled by the errant cells may perform erratically </li></ul><ul><li>Resultant dysfunction ranges from mild to incapacitating and often cause unconsciousness </li></ul><ul><li>When these uncontrolled, abnormal discharges occur repeatedly , a person is said to have an epileptic syndrome </li></ul>
  36. 36. CAUSES Epilepsy <ul><li>a brain injury, such as from a car crash or bike accident </li></ul><ul><li>an infection or illness that affected the developing brain of a fetus during pregnancy </li></ul><ul><li>lack of oxygen to an infant's brain during childbirth </li></ul><ul><li>meningitis, encephalitis, or any other type of infection that affects the brain </li></ul><ul><li>brain tumors or strokes </li></ul><ul><li>poisoning, such as lead or alcohol poisoning </li></ul>
  37. 37. Epilepsy Causes of newly diagnosed cases of epilepsy. Despite growing knowledge of causes, 70% of cases are of unknown cause. (from Hauser, 1990)
  38. 38. Epilepsy
  39. 39. Epilepsy
  40. 40. Epilepsy
  41. 41. Epilepsy
  42. 42. Epilepsy
  43. 43. DIAGNOSTIC FINDING: Epilepsy <ul><li>Electroencephalogram (EEG) - records the electrical activity of your brain via electrodes affixed to your scalp. People with epilepsy often have changes in their normal pattern of brain waves, even when they're not having a seizure.In some cases, your doctor may recommend video-EEG monitoring. This can be helpful because it allows your doctor to compare — second by second — the behaviors that occur during a seizure with your EEG pattern from exactly that same time. This helps your doctor pinpoint exactly where your seizures originate, which aids treatment decisions. </li></ul><ul><li>Computerized tomographies (CT) - Using special X-ray equipment, CT machines obtain images from many different angles and join them together to show cross-sectional images of your brain and skull. CT scans can reveal abnormalities in brain structure, including tumors, cysts, strokes or tangled blood vessels. This helps your doctor rule out other potential causes of your seizures. </li></ul>
  44. 44. DIAGNOSTIC FINDING: (cont’d) Epilepsy <ul><li>Magnetic resonance imaging (MRI) - An MRI machine uses radio waves and a strong magnetic field to produce detailed images of your brain. Like CT scans, MRIs can reveal brain abnormalities that could be causing your seizures. Dental fillings and braces may distort the images, so be sure to tell the technician about them before the test begins. </li></ul><ul><li>Positron emission tomography (PET) - use injected radioactive material to help visualize active areas of the brain. The radioactive material is tagged in a way that makes it attracted to glucose. Because the brain uses glucose for energy, the parts that are working harder will be brighter on a PET image. </li></ul><ul><li>Single-photon emission computerized tomography (SPECT) - This type of test is used primarily in people being evaluated for epilepsy surgery when the area of seizure onset is unclear on MRIs or EEGs. SPECT imaging requires two scans — one during a seizure and one 24 hours later. Radioactive material is injected for both scans and then the two results are compared. The area of the brain with the greatest activity during the seizure can be superimposed onto the person's MRI, to show surgeons exactly what portion of the brain should be removed. </li></ul>
  45. 45. MEDICAL MANAGEMENT Epilepsy <ul><ul><li>Intravenous diazepam, lorazepam, or fosphenytoin is </li></ul></ul><ul><ul><li>administered slowly in an attempt to halt the seizure </li></ul></ul><ul><li>To maintain seizure free state, other anticonvulsant medications </li></ul><ul><li>( carbamazepine, primidone, phenytoin, Phenobarbital, </li></ul><ul><li>ethosuximide and valproate) are prescribed </li></ul><ul><li>after the initial seizure is treated </li></ul><ul><ul><li>A. Pharmacological Therapy </li></ul></ul>
  46. 46. MEDICAL MANAGEMENT (cont’d) Epilepsy <ul><li>Surgery is indicated when epilepsy results from intracranial </li></ul><ul><ul><li>tumors, abscess, cysts or vascular anomalies </li></ul></ul><ul><li>Surgical removal of the epileptogenic focus is done for seizures </li></ul><ul><ul><li>that originate in a well-circumscribed area of the brain that can </li></ul></ul><ul><ul><li>be excised without producing significant neurologic defects </li></ul></ul><ul><ul><li>B. Surgical Management </li></ul></ul>
  47. 47. NURSING MANAGEMENT Epilepsy <ul><ul><li>A. Controlling Seizure </li></ul></ul><ul><li>Reduce fear that a seizure may occur unexpectedly by encouraging compliance with prescribed treatment </li></ul><ul><li>Emphasize that prescribed antiepileptic medication must be taken on a continuing basis and is not habit-forming </li></ul><ul><li>Prevent or control gingival hyperplasia, a side effect of phenytoin, by teaching patient to perform thorough oral hygiene and gum massage and seeking regular dental care Assess lifestyle and environment to determine factors that precipitate seizures such as emotional disturbances, environmental stressors, onset of menstruation, or fever </li></ul><ul><li>Encourage patient to follow a regular and moderate routine lifestyle, diet, exercise and rest </li></ul><ul><li>Advise patient to avoid photic stimulation (bright flickering lights, television viewing); dark glasses or covering one eye may help </li></ul><ul><li>Encourage patient to attend classes in stress management </li></ul>
  48. 48. NURSING MANAGEMENT (cont’d) Epilepsy <ul><ul><li>B. Improving Coping Mechanisms </li></ul></ul><ul><li>Understand that epilepsy imposes feelings of fear, alienation, depression, and uncertainty </li></ul><ul><li>Provide counseling to patient and family to help them understand the condition and limitations imposed </li></ul><ul><li>Encourage patient to participate in social and recreational activities </li></ul><ul><li>Instruct patient to avoid OTC medications unless approved by health care provider </li></ul><ul><li>Provide comprehensive mental health services to patients who exhibit symptoms of schizophrenia or impulsive or irritable behavior </li></ul>
  49. 49. NURSING MANAGEMENT (cont’d) Epilepsy <ul><ul><li>C. Promoting Home and Community Based Care </li></ul></ul><ul><li>Instruct patient and family about medication side effects and toxicity </li></ul><ul><li>Provide specific guidelines to assess and report signs and symptoms of overdose </li></ul><ul><li>Instruct patient to notify physician if unable to take medications due to illness </li></ul><ul><li>Teach patient to keep a drug and seizure chart, noting when medications are taken and any seizure activity </li></ul><ul><li>Instruct patient to take showers rather than tub baths to avoid drowning and never to swim alone </li></ul><ul><li>Educate patient to exercise in moderation in a temperature-controlled environment to avoid excessive heat </li></ul><ul><li>Encourage realistic attitude toward the disease; provide facts concerning epilepsy </li></ul><ul><li>Instruct patient to carry an emergency medical identification card or wear an identification bracelet </li></ul><ul><li>Advise patient to seek preconception and genetic counseling if desired </li></ul>
  50. 50. H E A D A C H E
  51. 51. <ul><li>the most common of all human physical complaints </li></ul><ul><li>not a disease entity but a symptom </li></ul><ul><li>it may indicate – organic disease, stress response, vasodilation, skeletal muscle tension </li></ul>DEFINITION Headache
  52. 52. COMMON LOCATIONS OF HEADACHE PAIN Headache
  53. 53. Headache The brain itself is not sensitive to pain, because it lacks pain-sensitive nerve fibers. Several areas of the head can hurt, including a network of nerves which extend over the scalp and certain nerves in the face, mouth and throat. The meninges and the blood vessels do not have pain receptors. Headache often results from traction to or irritation of the meninges and blood vessels. The muscle of the head may similarly sensitive to pain PATHOPHYSIOLOGY
  54. 54. Headache TYPES OF HEADACHE
  55. 55. Headache TYPES OF HEADACHE
  56. 56. Headache TYPES OF HEADACHE
  57. 57. Headache TYPES OF HEADACHE
  58. 58. Headache TYPES OF HEADACHE <ul><li>Composite drawing of two common methods of ICP monitoring </li></ul><ul><li>Iintra-ventricular catheter </li></ul><ul><li>Subarachnoid bolt </li></ul>
  59. 59. Headache TYPES OF HEADACHE
  60. 60. Headache TYPES OF SURGICAL PROCEDURES
  61. 61. Headache
  62. 62. Headache TYPES OF HEADACHE 1. Primary Headache <ul><li>no organic cause can be identified </li></ul><ul><li>include migraine, tension type (muscle contraction), and cluster headaches </li></ul>
  63. 63. Headache <ul><li>MIGRAINE </li></ul><ul><li>HEADACHE </li></ul><ul><ul><li>Strongly hereditary </li></ul></ul><ul><ul><li>More common in women </li></ul></ul><ul><ul><li>Tend to occur with stress or life crisis </li></ul></ul><ul><ul><li>Lasts for hour or days </li></ul></ul><ul><ul><li>One side of the head is more affected than the other </li></ul></ul>TYPES OF HEADACHE 1. Primary headache
  64. 64. Headache <ul><li>MIGRAINE HEADACHE </li></ul>KINDS OF MIGRAINE <ul><li>migraine with aura – characterized by a neurologic phenomenon that is experienced 10 to 30 minutes before the headache </li></ul><ul><li>migraine without aura – is the most prevalent type and may occur on one or both sides of the head; tiredness or mood changes may be experienced the day before the headache; nausea, vomiting, and photophobia often accompany </li></ul><ul><li>abdominal migraine – is most common in children with a family history of migraine </li></ul><ul><li>basilar artery migraine – disturbance of basilar artery in the brain stem; occurs primarily in young people </li></ul>TYPES OF HEADACHE 1. Primary headache
  65. 65. Headache <ul><li>MIGRAINE HEADACHE </li></ul>KINDS OF MIGRAINE (cont’d) TYPES OF HEADACHE 1. Primary headache <ul><li>carotidynia – also called lower half headache or facial migraine, produces deep, dull, aching and sometimes piercing pain in the jaw or neck; occur several times weekly and lasts a few minutes to hours; common in older people </li></ul><ul><li>headache free migraine – the presence of aura without headache </li></ul><ul><li>opthalmoplegic migraine – begins with a headache felt in the eye and is accompanied by vomiting; the eyelids droops (ptosis) and nerves responsible for eye movement become paralyzed; ptosis may persist for days or weeks </li></ul>
  66. 66. Headache CAUSE AND SYMTOMS CAUSE SYMTOMS dilatation of blood vessels a. nausea and vomiting b. chills c. fatigue d. irritability e. sweating f. edema
  67. 67. Headache CAUSE AND SYMTOMS
  68. 68. Headache FOUR PHASES OF MIGRAINE WITH AURA 1. PRODROME- experienced by 60% of patient symptoms: <ul><ul><li>depression </li></ul></ul><ul><ul><li>Irritability </li></ul></ul><ul><ul><li>feeling cold </li></ul></ul><ul><ul><li>increase urination </li></ul></ul><ul><ul><li>food craving </li></ul></ul><ul><ul><li>anorexia </li></ul></ul><ul><ul><li>change in activity level </li></ul></ul><ul><ul><li>diarrhea or constipation </li></ul></ul>
  69. 69. Headache 2. AURA PHASE <ul><ul><ul><li>occurs in up to 31% of patient having a migraine </li></ul></ul></ul><ul><ul><ul><li>less than an hour </li></ul></ul></ul><ul><ul><ul><li>characterized by focal neurologic symptoms such as visual disturbances and may be hemianopic </li></ul></ul></ul><ul><ul><ul><li>corresponds to the painless vasoconstriction </li></ul></ul></ul>FOUR PHASES OF MIGRAINE WITH AURA
  70. 70. Headache 2. AURA PHASE (cont’d) <ul><ul><ul><li>other symptoms include: </li></ul></ul></ul><ul><ul><li>numbness and tingling of the lips, face or hands </li></ul></ul><ul><ul><li>mild confusion </li></ul></ul><ul><ul><li>slight weakness of an extremity </li></ul></ul><ul><ul><li>drowsiness </li></ul></ul><ul><ul><li>dizziness </li></ul></ul>FOUR PHASES OF MIGRAINE WITH AURA
  71. 71. Headache 3. Headache Phase <ul><li>A throbbing headache intensifies over several hours </li></ul><ul><li>Severe and incapacitating </li></ul><ul><li>Associated with photophobia, nausea and vomiting </li></ul><ul><li>Duration varies from 4 – 72 hours </li></ul>FOUR PHASES OF MIGRAINE WITH AURA
  72. 72. Headache 4. Recovery Phase <ul><li>The pain gradually subsides </li></ul><ul><li>Muscle contraction in the neck and scalp is common </li></ul><ul><li>Associated with muscle ache and localized tenderness, exhaustion and mood changes </li></ul><ul><li>Physical exertion exacerbates headache pain </li></ul><ul><li>Posthead phase patient may sleep for extended periods </li></ul>FOUR PHASES OF MIGRAINE WITH AURA
  73. 73. Headache DIAGNOSTIC TEST FINDINGS <ul><li>CT scan : to rule out an underlying brain abnormality </li></ul><ul><li>EEG : to detect malfunctions of brain activity </li></ul><ul><li>SPINAL TAP : to detect infections and determine levels of white blood cells, glucose, and protein in the CSF </li></ul><ul><li>MRA: produces images of the blood vessels in the brain and is used to detect aneurysms and other vascular abnormalities </li></ul>
  74. 74. Headache TREATMENT <ul><li>Abortive ( symptomatic) approach – best employed in patients who suffer less frequent attacks; is aimed at relieving or limiting a headache at the onset or while it is in progress </li></ul><ul><li>Preventive approach – used in patients who experience more frequent attacks at regular or predictable intervals and may have medical conditions that preclude the use of abortive therapies </li></ul><ul><li>Triptans, serotonin receptor agonist – are the most specific antimigraine agents; cause vasoconstriction, reduce inflammation, and may reduce pain transmission </li></ul><ul><li>Ergotamine tartrate – acts on smooth muscle, causing prolonged constriction of the cranial blood vessels </li></ul><ul><li>Side effects include : aching muscle, paresthesias, nausea and vomiting </li></ul>
  75. 75. Headache TREATMENT (cont’d) chocolate, nuts, onions, cow’s milk, wheat, egg, orange, benzoic acid, cheese, tomato AVOID FOODS LIKE:
  76. 76. Headache B. TENSION HEADACHE <ul><li>Related to tension </li></ul><ul><li>Episodic, vary with stress </li></ul><ul><li>Usually bilateral, involves neck and shoulders </li></ul><ul><li>Characterized by a steady </li></ul><ul><li>Often bandlike or may be described as “a weight on top of my head” </li></ul>TYPES OF HEADACHE 1. Primary headache (cont’d)
  77. 77. Headache SYMTOMS AND TREATMENT SYMPTOMS TREATMENT sustained contraction of head and neck muscles <ul><li>Non narcotic analgesics </li></ul><ul><li>Relaxation technique </li></ul><ul><li>Amitriptyline </li></ul>
  78. 78. Headache C. CLUSTER HEADACHE <ul><li>More common in older men </li></ul><ul><li>Severe from vascular headache </li></ul><ul><li>Precipitated by alcohol or nitrate </li></ul><ul><li>Episodes cluster together in quick succession for few days or weeks with remission that lasts for months </li></ul><ul><li>Intense, throbbing, deep, often unilateral pain, begin in infraorbital region and spread to head and neck </li></ul><ul><li>Each attacks last 30 – 90 minutes and may have crescendo- decrescendo pattern </li></ul>TYPES OF HEADACHE 1. Primary headache (cont’d)
  79. 79. Headache SYMTOMS AND TREATMENT SYMPTOMS TREATMENT <ul><li>Flushing </li></ul><ul><li>Tearing of eyes </li></ul><ul><li>Nasal stuffiness </li></ul><ul><li>Sweating </li></ul><ul><li>Swelling of temporal vessels </li></ul><ul><li>Narcotic analgesic I.M. during acute phase </li></ul><ul><li>100% oxygen by face mask for 15 minutes </li></ul><ul><li>ergotamine tartrate </li></ul><ul><li>sumatripan </li></ul><ul><li>Steroids </li></ul><ul><li>Percutaneous sphenopalatine ganglion blockade </li></ul>
  80. 80. Headache D. CRANIAL ARTERITIS Cause of headache in older population, reaching its greatest incidence in those older than 70 years old TYPES OF HEADACHE 1. Primary headache (cont’d)
  81. 81. Headache SYMTOMS AND TREATMENT SYMPTOMS TREATMENT <ul><li>Fatigue </li></ul><ul><li>Malaise </li></ul><ul><li>Weight loss </li></ul><ul><li>Fever </li></ul><ul><li>Tender, swollen or nodular temporal artery is visible </li></ul>Early administration of corticosteroid to prevent the possibility of loss of vision due to vascular occlusion or rupture of the involved artery
  82. 82. Headache TYPES OF HEADACHE (cont’d) 2. Secondary Headache <ul><ul><li>Associated with organic cause such as brain tumor or aneurysm </li></ul></ul><ul><ul><li>Serious disorder related to headache include: </li></ul></ul><ul><li>brain tumors </li></ul><ul><li>subarachnoid hemorrhage </li></ul><ul><li>stroke </li></ul><ul><li>sever hypertension </li></ul><ul><li>meningitis </li></ul><ul><li>head injuries </li></ul>
  83. 83. Headache ASSESSMENT <ul><ul><li>Detailed history and physical assessment </li></ul></ul><ul><ul><li>Data obtained for the health history should reflect patient’s own words </li></ul></ul><ul><ul><li>Focus health history on assessment of headache (location, quality, frequency, precipitating factors, time, associated symptoms) </li></ul></ul>
  84. 84. Headache DIAGNOSTIC EVALUATION <ul><ul><li>Use to detect underlying cause such as tumor or aneurysm </li></ul></ul><ul><ul><ul><li>CT Scan </li></ul></ul></ul><ul><ul><ul><li>Cerebral angiography </li></ul></ul></ul><ul><ul><ul><li>MRI </li></ul></ul></ul><ul><ul><ul><li>EMG – reveal a contraction of the neck, scalp, or facial muscles </li></ul></ul></ul><ul><ul><ul><li>Laboratory Test </li></ul></ul></ul><ul><li>CBC </li></ul><ul><li>erythrocyte sedimentation rate </li></ul><ul><li>electrolytes </li></ul><ul><li>glucose </li></ul><ul><li>creatinine </li></ul><ul><li>thyroid hormone level </li></ul>
  85. 85. Headache FACTORS PRECIPITATING HEADACHE <ul><ul><li>Emotional problems </li></ul></ul><ul><ul><li>Stress </li></ul></ul><ul><ul><li>Sleep patterns </li></ul></ul><ul><ul><li>Recreational interest </li></ul></ul><ul><ul><li>Appetite </li></ul></ul><ul><ul><li>Family stressors </li></ul></ul>
  86. 86. Headache NURSING MANAGEMENT <ul><li>To enhance pain relief </li></ul><ul><li>To treat the acute event of the headache </li></ul><ul><li>To prevent recurrent episodes </li></ul>
  87. 87. Headache NURSING MANAGEMENT (cont’d) <ul><li>Attempt to abort headache early </li></ul><ul><li>Provide comfort measures(quite dark environment), elevate head 30 degrees </li></ul><ul><li>Provide symptomatic treatment such as antiemetics as indicated </li></ul><ul><li>RELIEVING PAIN </li></ul>
  88. 88. Headache NURSING MANAGEMENT (cont’d) <ul><li>Teach that migraine headaches are likely to occur when patient is ill, overtired, or feeling stressed </li></ul><ul><li>Instruct about the importance of proper diet, adequate rest, and coping strategies </li></ul><ul><li>Help patient identify circumstances that precipitate headache, and assist in development of alternative means of coping </li></ul><ul><li>Help patients develop insight into their feelings, behaviors, and conflicts to make necessary lifestyle modifications </li></ul><ul><li>Suggest regular periods of exercise and relaxation and avoidance of offending factors </li></ul><ul><li>Avoid long intervals between meals </li></ul><ul><li>Advise patient to awaken at the same time each day; disruption of normal sleeping pattern provokes a migraine in may patient </li></ul><ul><li>Promoting Home and Community based care </li></ul>
  89. 89. A L T E R E D LEVEL OF CONSCIOUSNESS CONSCIOUSNESS
  90. 90. Altered Level of Consciousness <ul><li>Is apparent in the patient who is not oriented, does not follow commands or needs persistent stimuli to achieved to achieved a state of alertness </li></ul><ul><li>Gauged in a continuum with a normal state of alertness and full cognition (consciousness) on one end and come on the other end </li></ul>
  91. 91. COMA <ul><li>Is a clinical state of unconsciousness in which the patient is unaware of self or the environment for prolonged periods (days to months or even years) </li></ul><ul><li>Light – response is by grimace or withdrawing limb from pain </li></ul><ul><li>Deep – absence of response to even the most painful stimuli </li></ul>Altered Level of Consciousness
  92. 92. <ul><li>Is a state of unresponsiveness to the environment in which the patient makes no movement or sound but sometimes opens the eyes </li></ul>Altered Level of Consciousness AKINETIC MUTISM
  93. 93. PERSISTENT VEGETATIVE STATE <ul><li>Is a condition in which the patient is described as wakeful but devoid of conscious content, without cognitive or affective mental function </li></ul>Altered Level of Consciousness
  94. 94. PATHOPHYSIOLOGY <ul><li>Altered LOC is not a disorder itself; rather, it is a result of multiple pathophysiologic phenomena. </li></ul>Altered Level of Consciousness
  95. 95. CAUSES Altered Level of Consciousness <ul><li>NEUROLOGIC –This could be a head injury, or a stroke. </li></ul><ul><li>TOXICOLOGIC – This could be a drug over dose, or alcohol intoxication. </li></ul><ul><li>METABOLIC – This could be hepatic or renal failure, DKA or diabetic ketoacidosis. </li></ul>
  96. 96. CLINICAL MANIFESTATIONS Altered Level of Consciousness <ul><li>Alterations in LOC occur along a continuum, and the clinical manifestations depend on where the patient is on the continuum. </li></ul><ul><li>As the patient’s state of alertness and consciousness decreases, change will ultimately occur in the pupillary response, eye opening response, verbal response, and motor response. </li></ul><ul><li>Initial alterations in LOC may be reflected by subtle behavioral changes, such as restlessness or increase anxiety. </li></ul><ul><li>The pupils, normally round and quickly reactive to light, becomes slugish (response is slower); as the patient becomes comatose, the pupils becomes fixed (no response to light). </li></ul><ul><li>The patient in a comma does not open the eyes, respond verbally, or move the extremities in response to do so. </li></ul>
  97. 97. ASSESSMENTS Altered Level of Consciousness <ul><ul><li>Particular attention to the neurologic system. It includes an evaluation of mental status, cranial nerve function, cerebral function (balance coordination); reflexes and motor and sensory function. </li></ul></ul><ul><ul><li>LOC a sensitive indicator of neurologic function, is assessed based on the criteria in the GLASSGOW COMA SCALE: eye opening, verbal response, and motor response. </li></ul></ul><ul><ul><li>If the patient is comatose and has localized signs such as abnormal pupillary and motor responses, it is assumed that neurologic disease is present until proven otherwise. </li></ul></ul><ul><li>If the patient is comatose but pupillary light reflexes are preserved, a toxic or metabolic disorder is suspected. </li></ul>
  98. 98. DIAGNOSTIC FINDINGS Altered Level of Consciousness <ul><ul><li>Computed Tomography (CT) scanning </li></ul></ul><ul><ul><li>Magnetic Resonance Imaging (MRI) </li></ul></ul><ul><ul><li>Electro-encephalography </li></ul></ul><ul><ul><li>Less common procedure include </li></ul></ul><ul><ul><li>Pistron Emission Tomography (PET) </li></ul></ul><ul><ul><li>Single Photon Emission Computed Tomogrophy (SPECT) </li></ul></ul><ul><ul><li>Laboratory tests include: </li></ul></ul><ul><ul><ul><li>analysis of blood glucose, </li></ul></ul></ul><ul><ul><ul><li>electrolytes, </li></ul></ul></ul><ul><ul><ul><li>serum ammonia, </li></ul></ul></ul><ul><ul><ul><li>liver function tests; </li></ul></ul></ul><ul><ul><ul><li>blood urea nitrogen levels; </li></ul></ul></ul><ul><ul><ul><li>serum osmolality; </li></ul></ul></ul><ul><ul><li>calcium level, </li></ul></ul>
  99. 99. COMPLICATIONS Altered Level of Consciousness <ul><li>Respiratory failure - develop shortly after the patient becomes unconscious. If the patient cannot maintain effective respirations, care (insertion of an airway, mechanical ventilation) is initiated to provide adequate ventilation and protect the airway. </li></ul><ul><li>Pneumonia - common in patients receiving mechanical ventilation or in those who cannot maintain and clear the airway. </li></ul><ul><li>Pressure ulcers - may become infected and serve as a source of sepsis. </li></ul><ul><li>Aspiration - aspiration of gastric contents or feedings may occur, precipitating the development of aspiration pneumonia or airway occlussion. </li></ul>
  100. 100. MEDICAL MANAGEMENT Altered Level of Consciousness <ul><li>The first priority of treatment is to obtain and maintain a patent airway. </li></ul><ul><li>The patient may be orally or nasally intubated, or a tracheostomy may be performed. </li></ul><ul><li>Mechanical ventilator is used to maintain adequate oxygenation and ventilation. </li></ul><ul><li>The circulatory status (blood pressure and heart rate) is monitored to ensure adequate perfusion to the body and brain. </li></ul><ul><li>An intravenous (IV) catheter is inserted to provide access for IV fluids and medications. </li></ul><ul><li>Neurologic care focuses on the specific neurologic pathology, if known. </li></ul><ul><li>Nutritional support, via a feeding tube or a gastrostomy tube, is initiated as soon as possible </li></ul><ul><li>Other medical interventions are aimed at pharmacologic management and prevention of complications </li></ul>
  101. 101. NURSING MANAGEMENT Altered Level of Consciousness <ul><li>To establish an adequate airway and ventilation </li></ul><ul><li>Position the patient in lateral or semiprone position; do not allow the patient to remain on back </li></ul><ul><li>Remove secretions to reduce danger of aspiration; elevate head of bed to a 30 – degree angle to prevent aspiration; provide frequent suctioning and oral hygiene </li></ul><ul><li>Monitor number and consistency of bowel movements; perform rectal examination for signs of fecal impaction; patient may require enema every other day to empty lower colon </li></ul><ul><li>Enemas may be contraindicated if valsalva maneuver increase intracranial pressure </li></ul><ul><li>Administer stool softeners and glycerin suppositories as indicated </li></ul>Maintaining the airway
  102. 102. NURSING MANAGEMENT (cont’d) Altered Level of Consciousness <ul><li>Reinforce and clarify information about patient’s condition to permit family members to mobilize their own adaptive capacities </li></ul><ul><li>Encourage ventilation of feelings and concerns </li></ul><ul><li>Support family in decision making process concerning posthospital management and placement </li></ul>Supporting the Family
  103. 103. NURSING MANAGEMENT (cont’d) Altered Level of Consciousness <ul><li>To help patient to over come profound sensory deprivation </li></ul><ul><li>Make efforts to maintain usual day and night patterns of activity and sleep </li></ul><ul><li>Touch and talk to patient </li></ul>Promoting Sensory Stimulation
  104. 104. NURSING MANAGEMENT (cont’d) Altered Level of Consciousness <ul><li>Begin to teach activities of daily as soon as consciousness returns </li></ul><ul><li>Support, encourage, and supervise patient’s effort </li></ul>Attaining Self Care
  105. 105. I N T R A C R A N I A L I N C R E A S E D P R E S S U R E
  106. 106. Increased Intracranial Pressure Is the result of the amount of brain tissue, blood, and cerebrospinal fluid (CSF) within the skull at any one time. The volume and pressure of these three components are usually in a state of equilibrium. Because there is limited space for expansion within the skull, an increase in any of these components causes a change in the volume of the others by displacing or shifting CSF, increasing the absorption of CSF, or decreasing cerebral blood volume. The normal ICP is 10 to 20 mm Hg. Although elevated ICP is most commonly associated with head injury, an elevated pressure may be seen secondary to brain tumors, subarachnoid hemorrhage, and toxic and vital encephathies. Increased ICP from any cause affects cerebral perfusion and produces distortion and shifts of brain tissue
  107. 107. CLINIICAL MANIFESTATION Increased Intracranial Pressure When ICP increases to the point where the brain’s ability to adjust has reached its limits, neural function is impaired. Increased ICP is manifested by changes in level of consciousness and abnormal respiratory and vasomotor responses.
  108. 108. CLINIICAL MANIFESTATION (cont’d) Increased Intracranial Pressure <ul><li>Level of responsiveness and consciousness is the most important indicator of the patient’s condition. </li></ul><ul><li>Lethargy is the earliest sign of increasing ICP. Slowing of speech and delay in response to verbal suggestions are early indicators. </li></ul><ul><li>Sudden change in condition, such as restlessness (without apparent cause), confusion, or increasing drowsiness, has neurologic significance. </li></ul><ul><li>Decreased cerebral perfusion pressure (CPP) can result in a Cushing’s response and Cushing’s triad (bradycardia, bradypnea, and hypertension); widening pulse pressure us an ominous sign. </li></ul><ul><li>As pressure increase, patient becomes stuporous and reach only to loud auditory or painful stimuli. This indicates serious impairment of brain circulation, and immediate surgical intervention may be required. With further deterioration, coma and abnormal motor responses in the form of decortication, decerebration, or flaccidity may occur. </li></ul><ul><li>When coma is profound, pupils are dilated and fixed, respirations are impaired, and death is usually inevitable. </li></ul>
  109. 109. ASSESSMENT AND DIAGNOSTIC METHODS Increased Intracranial Pressure <ul><li>Cerebral angiography, computed tomography (CT), magnetic resonance imaging (MRI), pistron emission tomography (PET), transcranial Doppler studies, or electrophysiologic monitoring may be done. Lumbar puncture is avoided to prevent risking herniation. </li></ul><ul><li>ICP monitoring provides useful information (ventriculostomy, subarachnoid bolt.screw, epidural monitor, fiberoptic monitor). </li></ul>
  110. 110. MEDICAL MANAGEMENT Increased Intracranial Pressure Increased ICP is a true emergency and must be treated promptly. Immediate management involves decreasing cerebral edema, lowering the volume of CSF, and decreasing blood volume while maintaining cerebral perfusion.
  111. 111. PHARMACOLOGIC THERAPY Increased Intracranial Pressure <ul><li>Osmotic diuretics and corticosteriod are administered, fluid is restricted, CSF is drained, patient is hyperventilated, fever is controlled (using antipyretics, hypothermia blanker, with chlorpromazine {Thorazine} to control shivering), and cellular metabolic demands are reduced (with barbiturates, paralyzing agents). </li></ul><ul><li>If patient does not respond to conventional treatment, cellular metabolic demands may be reduced by administering high doses of barbiturates or administering pharmacologic paralyzing agents, such as pancuronium (Pavulon). </li></ul><ul><li>Patient requires care in a critical care unit </li></ul>
  112. 112. NURSING MANAGEMENT Increased Intracranial Pressure T H E U N C O N S C I O U S P A T I E N T ASSESSMENT <ul><li>Obtain patient history with subjective data, including events leading to present illness. </li></ul><ul><li>Complete a neurologic examination as patient’s condition allows. </li></ul><ul><li>Use the Glasgrow Coma Scale to assess verbal response, motor response, and eye opening behaviors. </li></ul><ul><li>Note subtle changes, such as restlessness, headache, forced breathing, mental cloudiness, and purposeless movements, which may be early indications of rising ICP. </li></ul><ul><li>Assess headache (usually constant, increasing in intensity, and aggravated by movement or straining). </li></ul><ul><li>Note recurrent or projectile vomiting, which indicates increased pressure. </li></ul><ul><li>Monitor ICP closely as an essential part of management. </li></ul><ul><li>Inspect pupils for change; observe size configuration, reaction to light, and gaze (conjugate [paired and working together] or disconjugate). Also assess ability of eyes to abduct or adduct. Inspect retina and optic nerve for hemorrhage and papilledema. </li></ul>
  113. 113. NURSING MANAGEMENT Increased Intracranial Pressure NURSING ALERT! Changes in vital signs may be a late sign of increased ICP. As ICP increases, pulse rate and respiratory rate decreased, and blood pressure and temperature rise. Observe for widening pulse pressure, bradycardia, and respiratory irregularity: Cheyne-Storked breathing and ataxic breathing (Cushing’s triad). Widened pulse pressure is a serious development. Immediate surgical intervention is indicated if the major circulation begins to decrease as a result of brain compression.
  114. 114. DIAGNOSIS Increased Intracranial Pressure <ul><li>Ineffective airway clearance related to accumulation of secretions secondary to depressed level of responsiveness </li></ul><ul><li>Ineffective cerebral tissue perfusion related to effects of increased ICP </li></ul><ul><li>Ineffective breathing patterns related to neurologic dysfunction (brain stem compression, structural displacement) </li></ul><ul><li>Risk for fluid volume deficit related to dehydration procedures </li></ul><ul><li>Risk for infection related to ICP monitoring system (fiberoptic or intraventricular catheter) </li></ul>NURSING DIAGNOSES
  115. 115. DIAGNOSIS (cont’d) Increased Intracranial Pressure <ul><li>Brain stem herniation </li></ul><ul><li>Diabetes insipidus </li></ul><ul><li>Syndrome of inappropriate antidiuretic hormone (SIADH) secretion </li></ul>COLLABORATIVE PROBLEMS / POTENTIAL COMPLICATIONS
  116. 116. PLANNING OF GOALS Increased Intracranial Pressure The major goals of the patient may include adequate cerebral tissue perfusion through reduction of ICP, normal respiration, patent airways, restored fluid balance, normal urine and bowel elimination, absence of infection, and absence of complications.
  117. 117. NURSING INTERVENTION Increased Intracranial Pressure <ul><li>Maintain patency of the airway; oxygenate patient before and after suctioning. </li></ul><ul><li>Auscultate lung fields for adventitious sounds every 8 hours </li></ul><ul><li>Elevate head of bed to help clear secretions and improve venous drainage of the brain. </li></ul><ul><li>Discourage coughing and straining </li></ul>MAINTAINING A PATENT AIRWAY
  118. 118. NURSING INTERVENTION (cont’d) Increased Intracranial Pressure <ul><li>Monitor constantly for respiratory irregularities. </li></ul><ul><li>Collaborate with respiratory therapist in monitoring arterial carbon dioxide pressure (PaCO2), which is usually maintained between 35 and 45 mm Hg when hyperventilation therapy is used. </li></ul><ul><li>Maintain continuous neurologic observation record with repeated assessments. </li></ul>ATTAINING NORMAL RESPIRATORY PATTERN
  119. 119. NURSING INTERVENTION (cont’d) Increased Intracranial Pressure <ul><li>Monitor for bradycardia, bradypnea, and rising blood pressure (Cushing’s reflex or response) </li></ul><ul><li>Avoid raising jugular venous pressure and ICP by keeping patient’s head in a neutral (midline) position and maintaining slight elevation of the head to aid in venous drainage. </li></ul><ul><li>Avoid extreme rotation and flexion of the neck, because compression or distortion of the jugular veins increases ICP. </li></ul><ul><li>Avoid extreme hip flexion: this postion causes and increase in intra-abdominal and intrathoracic pressures, which produce a rise in ICP. </li></ul><ul><li>Instruct patient to exhale when moving or turning in bed to avoid the Valsalva maneuver. </li></ul>PRESERVING AND IMPROVING CEREBRAL TISSUE PERFUSION
  120. 120. NURSING INTERVENTION (cont’d) Increased Intracranial Pressure <ul><li>Provide stool softeners and a high-fiber diet if patient can eat; note any abdominal distention. </li></ul><ul><li>Avoid isometric muscle contractions. </li></ul><ul><li>Avoid suctioning longer than15 seconds; hyperventilate on ventilator with 100% oxygen before suctioning. </li></ul><ul><li>Maintain a calm atmosphere and reduce environmental stimuli; avoid emotional stress. </li></ul><ul><li>Avoid enemas and cathartics. </li></ul><ul><li>Pace interventions to prevent transient increase in ICP. During nursing care, ICP should not rise above 25mm Hg and should return to baseline within 5 minutes. </li></ul>PRESERVING AND IMPROVING CEREBRAL TISSUE PERFUSION (cont’d)
  121. 121. NURSING INTERVENTION (cont’d) Increased Intracranial Pressure <ul><li>Asses skin turgor, mucous membranes, and serum and urine osmolality for signs for dehydration. </li></ul><ul><li>Monitor vital signs to assess fluid volume status. </li></ul><ul><li>Give oral hygiene for mouth dryness. </li></ul><ul><li>Insert indwelling catheter to assess renal and fluid status. </li></ul><ul><li>Monitor urine output every hour in the acute phase. </li></ul><ul><li>Administer intravenous fluids by pump at a slow to moderate rate; monitor patients receiving mannitol for congestive failure. </li></ul><ul><li>Administer conrticosteriods and dehydrating agents as ordered. </li></ul><ul><li>Test strools for blood if patient is on high doses of corticosteriods (gastrointestinal bleeding is complication). </li></ul>MAINTAINING NEGATIVE FLUID BALANCE
  122. 122. NURSING INTERVENTION (cont’d) Increased Intracranial Pressure <ul><li>Strictly adhere to the facility’s written protocols for managing ICP monitoring systems. </li></ul><ul><li>Keep dressing over ventricular catheters dry, because wet dressings are conducive to bacterial growth. </li></ul><ul><li>Use aseptic technique at all times when managing the ventricular drainage system and changing drainage bag. </li></ul><ul><li>Check carefully for any loose connections that cause leaking and contamination of the ventricular system and contamination of CSF as well as inaccurate ICP readings. </li></ul><ul><li>Monitor for signs and symptoms of meningitis: fever, chills, nuchal (neck) rigidity, and increasing or persistent headache. </li></ul>PREVENTING INFECTION
  123. 123. NURSING INTERVENTION (cont’d) Increased Intracranial Pressure <ul><li>ICP elevation : monitor ICP closely for continuous elevation or significant increase over baseline; assess vital signs at time of ICP increase. Assess for and immediately report manifestations increasing ICP. </li></ul><ul><li>Impending brain herniation: monitor for increase in blood pressure, decrease in pulse, and change in papillary response. </li></ul><ul><li>Patients not on paralyzing agents may change from decerebrate to decorticate posturing to a flaccid or rag-doll appearance; this requires rapid intervention using mannitol or drainage of CSF. Monitor urine output closely. </li></ul><ul><li>Diabetes insipidus requires fluid and electrolyte replacement and administration of vasopressin; monitor serum electrolytes for replacement. </li></ul><ul><li>SIADH requires fluid restriction and serum electrolyte monitoring. </li></ul>MONITORING AND MANAGING POTENTION COMPLICATIONS
  124. 124. EVALUATION Increased Intracranial Pressure EXPECTED PATIENT OUTCOMES <ul><li>Remains free of excessive airways secretions; airways is patent </li></ul><ul><li>Attains normal respirations </li></ul><ul><li>Demonstrates improved cerebral tissue perfusion </li></ul><ul><li>Attains improved fluid balance </li></ul><ul><li>Has no sign of infection </li></ul><ul><li>Remains free of complications </li></ul>
  125. 125. thank you

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