Seizurepptetc 091214081634 Phpapp01

Seizure Disorder page 1
By: Erika Faye E. Docog

Dr. Anthony P. Toledo
MSNET2
DEFINITION
Involuntary muscle contractions
caused by abnormal discharged of
electrical impulses from nerve cells

CLASSIFICATION

+Generalized absence (petit mal)
+Generalized tonic-clonic (grand mal)
+Myolonic
+Atonic

; Generalized seizures
; Partial seizures (focal seizures)
+Simple partial
+Complex partial


CLASSIFICATION
; Partial seizures (focal seizures)

CLASSIFICATION
; Generalized seizures
CLASSIFICATION
; Unclassified seizures
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


CLASSIFICATION
; Unclassified seizures (contd)
CLASSIFICATION
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


CLASSIFICATION
CLASSIFICATION
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

CLASSIFICATION
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

CLASSIFICATION
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;
- Doesnt 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

CAUSES


PATHOPHYSIOLOGY
_ Many neurons fire in a synchronous pattern, resulting in a
transient physiologic disturbance
_ Physiologic disturbances include abnormal movements,
abnormal sensations and change in LOC
ASSESSMENT FINDINGS
Aura
LOC
Dyspnea
Fixed and dilated pupil
Incontinence

DIAGNOSTIC TEST FINDINGS
+EEG: abnormal wave patterns, focus of seizure activity
+CT scan: a space occupying lesion
+MRI: pathologic changes
+BRAIN MAPPING: identification of seizure areas

MEDICAL MANAGEMENT
Diet: Ketogenic (a diet high in fats and proteins, and low in carbohydrates)
I.V. therapy: saline lock
Activity: bed rest
Monitoring: Vital signs, I/O, and neurovital signs
Laboratory studies: glucose, potassium, and anticonvulsant drug levels if
applicable
Special care: seizure precautions
Anticonvulsants: phenytoin (Dilantin), ethosuximide (Zarontin),
Phenobarbital (Luminal), Carbamazepine (Tegretol), valporic acid (Depakote),
gabapentin (Neurontin), lamotrigine (Lamictal), topiramote (Topamax)

NURSING CARE DURING SEIZURE
Provide privacy and protect the patient from curios on-lookers,
Ease the patient to the floor, if possible
Protect the head with a pad to prevent injury (from striking a hard surface)
Loosen constrictive clothing
Push aside any furniture that may injure the patient during the seizure
If the patient is on bed, remove the pillows and raise side rails
If an aura precedes the seizure, insert an oral airway to reduce the possibility of the
tongue or cheek being bitten

NURSING CARE DURING SEIZURE (contd)
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
No attempt should be made to restrain the patient during the seizure because
muscular contractions are strong and restraint can produce injury
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



A generalized tonic clonic seizure. Here the
whole brain is affecting from the beginning.
In:
(a) there is a cry and loss of consciousness,
arms flex up then extend in
(b) 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
(c) the jerking is slowing down and will
eventually stop. In
(d) the man has been placed on his side to aid
breathing and to keep the airway clear.
NURSING CARE AFTER THE SEIZURE
Keep the patient on one side to prevent aspiration. Make sure the airway
is patent
There is usually a period of confusion after a grand mal seizure
A short apneic period may occur during or immediately after a generalized
seizure
The patient, on awakening, should be reoriented to the environment
If the patients becomes agitated after a seizure (postictal), use calm
persuasion and gentle restraint

PATIENT EDUCATION
Take medications at regular basis
Avoid alcohol. This lowers seizure threshold
Adequate rest
Well-balanced diet
Avoid driving, operating machines, swimming until seizures are well
controlled
Lead an active life

DEFINITION
Acute prolonged seizure activity
Is a series of generalized seizures that occur without full recovery of
consciousness between attacks
Produces cumulative effects
Brain damage may occur secondary to prolonged hypoxia and exhaustion
The client is often in coma for 12 to 24 hours or longer, during which time
recurring seizures occur
The attack is usually related to failure to take prescribed anticonvulsants
CAUSES
o Perinatal hypoxia or anoxia that injures the brain
o Meningitis
o Metabolic disorder
In infants
In adults
o Infections of the brain,
o Strokes
o Brain tumors
o Severe head trauma
PATHOPHYSIOLOGY
The exact pathophysiology of why seizure
evolves into status
is complex and not fully understood
DIAGNOSTIC FINDINGS
; EEG to monitor response to treatment
; BLOOD TEST glucose, electrolytes, liver functions
and illicit substances
MEDICAL MANAGEMENT
GOAL
to stop the seizure as quickly as possible
to ensure adequate cerebral oxygenation,
to maintain the patient in a seizure free state
MEDICAL MANAGEMENT (contd)
cuffed endotracheal tube is inserted - - - if the patient remains
unconscious and unresponsive
Intravenous diazepam (valium), lorazepam (ativan), or fosphynetoin
(cerebyx) - - - is given slowly in an attempt to halt seizure immediately
Other medications (phynetoin, Phenobarbital) - - - given later to maintain
a seizure free state
Blood samples are obtained - - - to monitor serum electrolytes, glucose,
and phynetoin levels
EEG monitoring - - - useful in determining the nature of seizure activity
IV infusion of dextrose - - - given if the seizure is due to hypoglycemia
NURSING MANAGEMENT
Initiates ongoing assessment and monitoring of respiratory and cardiac
functioning
Monitoring and documenting the seizure activity and the patients
responsiveness
The patient is turned to a side lying position to assist in draining
pharyngeal secretions
The IV line must be closely monitored because it may be dislodged during
seizure
RECOVERY AND REHABILITATION
*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.
*The longer the seizure persist, the greater the chance of cerebral injury
*A complication of status epilepticus can actually be the development of
epilepsy in a percentage cases.
DEFINITION
Group of syndromes characterized by recurring seizures
Epileptic syndromes are classified by specific patterns of clinical features,
including age of onset, family history and seizure type
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)
Can follow
-birth trauma,
-asphysia neonatorum,
-head injuries,
-some infectious disease ( bacterial, viral, parasitic )
-toxicity ( carbon dioxide and lead poisoning )
-circulatory problems
-fever, metabolic and nutritional disorder
-drug or alcohol intoxication
also associated with brain tumors, abscess, and congenital malformations
PATHOPHYSIOLOGY
Messages from the body are carried by the neurons of the brain by means
of discharges of electrochemical energy that sweep along them.
These impulses occur in burst whenever a nerve cell has a task to perform.
Sometimes, these cells or groups of cells continue firing after the task is
finished
During the period of unwanted discharges, parts of the body controlled by
the errant cells may perform erratically
Resultant dysfunction ranges from mild to incapacitating and often cause
unconsciousness
When these uncontrolled, abnormal discharges occur repeatedly , a person
is said to have an epileptic syndrome
CAUSES
:a brain injury, such as from a car crash or bike accident
:an infection or illness that affected the developing brain of a fetus during
pregnancy
:lack of oxygen to an infant's brain during childbirth
:meningitis, encephalitis, or any other type of infection that affects the brain
:brain tumors or strokes
:poisoning, such as lead or alcohol poisoning
Remote
symptomatic
30%
Idiopathic /
cryptogenic
70%
Causes of newly diagnosed cases of epilepsy. Despite growing
knowledge of causes, 70% of cases are of unknown cause.
(from Hauser, 1990)
DIAGNOSTIC FINDING:
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.
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.
DIAGNOSTIC FINDING: (contd)
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.
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.
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.
MEDICAL MANAGEMENT
* Intravenous diazepam, lorazepam, or fosphenytoin is
administered slowly in an attempt to halt the seizure

* To maintain seizure free state, other anticonvulsant medications
( carbamazepine, primidone, phenytoin, Phenobarbital,
ethosuximide and valproate) are prescribed
after the initial seizure is treated
A. Pharmacological Therapy
MEDICAL MANAGEMENT (contd)
* Surgery is indicated when epilepsy results from intracranial
tumors, abscess, cysts or vascular anomalies

* Surgical removal of the epileptogenic focus is done for seizures
that originate in a well-circumscribed area of the brain that can
be excised without producing significant neurologic defects
B. Surgical Management
NURSING MANAGEMENT
A. Controlling Seizure
Reduce fear that a seizure may occur unexpectedly by encouraging compliance with
prescribed treatment
Emphasize that prescribed antiepileptic medication must be taken on a continuing basis
and is not habit-forming
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
Encourage patient to follow a regular and moderate routine lifestyle, diet, exercise and
rest
Advise patient to avoid photic stimulation (bright flickering lights, television viewing); dark
glasses or covering one eye may help
Encourage patient to attend classes in stress management
NURSING MANAGEMENT (contd)
B. Improving Coping Mechanisms
Understand that epilepsy imposes feelings of fear, alienation, depression, and
uncertainty
Provide counseling to patient and family to help them understand the condition
and limitations imposed
Encourage patient to participate in social and recreational activities
Instruct patient to avoid OTC medications unless approved by health care provider
Provide comprehensive mental health services to patients who exhibit symptoms
of schizophrenia or impulsive or irritable behavior
C. Promoting Home and Community Based Care
Instruct patient and family about medication side effects and toxicity
Provide specific guidelines to assess and report signs and symptoms of overdose
Instruct patient to notify physician if unable to take medications due to illness
Teach patient to keep a drug and seizure chart, noting when medications are taken and
any seizure activity
Instruct patient to take showers rather than tub baths to avoid drowning and never to
swim alone
Educate patient to exercise in moderation in a temperature-controlled environment to
avoid excessive heat
Encourage realistic attitude toward the disease; provide facts concerning epilepsy
Instruct patient to carry an emergency medical identification card or wear an
identification bracelet
Advise patient to seek preconception and genetic counseling if desired
the most common of all human physical complaints
not a disease entity but a symptom
it may indicate organic disease, stress response, vasodilation,
skeletal muscle tension
DEFINITION

COMMON
LOCATIONS OF
HEADACHE PAIN


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

TYPES OF HEADACHE

TYPES OF HEADACHE

TYPES OF HEADACHE

TYPES OF HEADACHE

TYPES OF HEADACHE
Composite drawing of two common methods
of ICP monitoring
(A) Iintra-ventricular catheter
(B) Subarachnoid bolt

TYPES OF HEADACHE

TYPES OF SURGICAL PROCEDURES


TYPES OF HEADACHE
1. Primary Headache
+no organic cause can be identified
+include migraine, tension type (muscle contraction), and cluster headaches

Strongly hereditary
More common in women
Tend to occur with stress or life crisis
Lasts for hour or days
One side of the head is more affected than the other
TYPES OF HEADACHE
1. Primary headache

A. MIGRAINE HEADACHE
KINDS OF MIGRAINE
i. migraine with aura characterized by a neurologic phenomenon that is
experienced 10 to 30 minutes before the headache
ii. 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
iii. abdominal migraine is most common in children with a family history of
migraine
iv. basilar artery migraine disturbance of basilar artery in the brain stem;
occurs primarily in young people
TYPES OF HEADACHE
1. Primary headache

A. MIGRAINE HEADACHE
KINDS OF MIGRAINE (contd)
TYPES OF HEADACHE
1. Primary headache
v. 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
vi. headache free migraine the presence of aura without headache
vii. 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

CAUSE AND SYMTOMS
CAUSE
SYMTOMS
dilatation of blood
vessels
a. nausea and vomiting
b. chills
c. fatigue
d. irritability
e. sweating
f. edema

CAUSE AND SYMTOMS

FOUR PHASES OF MIGRAINE WITH AURA
1. PRODROME- experienced by 60% of patient symptoms:
*depression
*Irritability
*feeling cold
*increase urination
*food craving
*anorexia
*change in activity level
*diarrhea or constipation

2. AURA PHASE
;occurs in up to 31% of patient having a migraine
;less than an hour
;characterized by focal neurologic symptoms such as visual
disturbances and may be hemianopic
;corresponds to the painless vasoconstriction

2. AURA PHASE (contd)
;other symptoms include:
@numbness and tingling of the lips, face or hands
@mild confusion
@slight weakness of an extremity
@drowsiness
@dizziness

3. Headache Phase
A throbbing headache intensifies over several hours
Severe and incapacitating
Associated with photophobia, nausea and vomiting
Duration varies from 4 72 hours

4. Recovery Phase
The pain gradually subsides
Muscle contraction in the neck and scalp is common
Associated with muscle ache and localized tenderness, exhaustion and
mood changes
Physical exertion exacerbates headache pain
Posthead phase patient may sleep for extended periods

DIAGNOSTIC TEST FINDINGS
CT scan: to rule out an underlying brain abnormality
EEG: to detect malfunctions of brain activity
SPINAL TAP: to detect infections and determine levels of white blood cells,
glucose, and protein in the CSF
MRA: produces images of the blood vessels in the brain and is used to
detect aneurysms and other vascular abnormalities

TREATMENT
1. 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
2. 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
3. Triptans, serotonin receptor agonist are the most specific
antimigraine agents; cause vasoconstriction, reduce inflammation, and
may reduce pain transmission
4. Ergotamine tartrate acts on smooth muscle, causing prolonged
constriction of the cranial blood vessels
5. Side effects include: aching muscle, paresthesias, nausea and vomiting

TREATMENT (contd)
chocolate,
nuts,
onions,
cows milk,
wheat,
egg,
orange,
benzoic acid,
cheese,
tomato
AVOID FOODS LIKE:

+Related to tension
+Episodic, vary with stress
+Usually bilateral, involves neck and shoulders
+Characterized by a steady
+Often bandlike or may be described as a weight on top of my head
TYPES OF HEADACHE
1. Primary headache (contd)

SYMTOMS AND TREATMENT
SYMPTOMS
TREATMENT
sustained contraction of
head and neck muscles
Non narcotic analgesics
Relaxation technique
Amitriptyline

More common in older men
Severe from vascular headache
Precipitated by alcohol or nitrate
Episodes cluster together in quick succession for few days or weeks with
remission that lasts for months
Intense, throbbing, deep, often unilateral pain, begin in infraorbital region and
spread to head and neck
Each attacks last 30 90 minutes and may have crescendo- decrescendo
pattern
TYPES OF HEADACHE

SYMPTOMS
TREATMENT
;Flushing
;Tearing of eyes
;Nasal stuffiness
;Sweating
;Swelling of temporal
vessels
ENarcotic analgesic I.M. during acute phase
E100% oxygen by face mask for 15 minutes
Eergotamine tartrate
Esumatripan
ESteroids
EPercutaneous sphenopalatine ganglion
blockade

Cause of headache in older population, reaching its greatest incidence in
those older than 70 years old
TYPES OF HEADACHE

SYMPTOMS
TREATMENT
Fatigue
Malaise
Weight loss
Fever
Tender, swollen or
nodular temporal artery is
visible
Early administration of corticosteroid to
prevent the possibility of loss of vision due to
vascular occlusion or rupture of the involved
artery

TYPES OF HEADACHE (contd)
2. Secondary Headache
Associated with organic cause such as brain tumor or aneurysm
Serious disorder related to headache include:
brain tumors
subarachnoid hemorrhage
stroke
sever hypertension
meningitis
head injuries

ASSESSMENT
+Detailed history and physical assessment
+Data obtained for the health history should reflect patients own words
+Focus health history on assessment of headache (location, quality,
frequency, precipitating factors, time, associated symptoms)

DIAGNOSTIC EVALUATION
IUse to detect underlying cause such as tumor or aneurysm
ICT Scan
ICerebral angiography
IMRI
IEMG reveal a contraction of the neck, scalp, or facial muscles
ILaboratory Test
CBC
erythrocyte sedimentation rate
electrolytes
glucose
creatinine
thyroid hormone level

FACTORS PRECIPITATING HEADACHE
Emotional problems
Stress
Sleep patterns
Recreational interest
Appetite
Family stressors

NURSING MANAGEMENT
+To enhance pain relief
+To treat the acute event of the headache
+To prevent recurrent episodes

Attempt to abort headache early
Provide comfort measures(quite dark environment), elevate
head 30 degrees
Provide symptomatic treatment such as antiemetics as
indicated
RELIEVING PAIN

Teach that migraine headaches are likely to occur when patient is ill, overtired, or
feeling stressed
Instruct about the importance of proper diet, adequate rest, and coping strategies
Help patient identify circumstances that precipitate headache, and assist in
development of alternative means of coping
Help patients develop insight into their feelings, behaviors, and conflicts to make
necessary lifestyle modifications
Suggest regular periods of exercise and relaxation and avoidance of offending factors
Avoid long intervals between meals
Advise patient to awaken at the same time each day; disruption of normal sleeping
pattern provokes a migraine in may patient
Promoting Home and Community based care
Altered Level of Consciousness
*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
*Gauged in a continuum with a normal state of alertness and full
cognition (consciousness) on one end and come on the other end
COMA
*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)
*Light response is by grimace or withdrawing limb from pain
*Deep absence of response to even the most painful stimuli
oIs a state of unresponsiveness to the environment in which the
patient makes no movement or sound but sometimes opens the
eyes
AKINETIC MUTISM
PERSISTENT VEGETATIVE STATE
oIs a condition in which the patient is described as wakeful but
devoid of conscious content, without cognitive or affective mental
function
PATHOPHYSIOLOGY
oAltered LOC is not a disorder itself; rather, it is a result of multiple
pathophysiologic phenomena.
CAUSES
;NEUROLOGIC This could be a head injury, or
a stroke.
;TOXICOLOGIC This could be a drug over
dose, or alcohol intoxication.
;METABOLIC This could be hepatic or renal
failure, DKA or diabetic ketoacidosis.
CLINICAL MANIFESTATIONS
Alterations in LOC occur along a continuum, and the clinical manifestations
depend on where the patient is on the continuum.
As the patients state of alertness and consciousness decreases, change will
ultimately occur in the pupillary response, eye opening response, verbal
response, and motor response.
Initial alterations in LOC may be reflected by subtle behavioral changes, such
as restlessness or increase anxiety.
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).
The patient in a comma does not open the eyes, respond verbally, or move
the extremities in response to do so.
ASSESSMENTS
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.
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.
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.
If the patient is comatose but pupillary light reflexes are preserved, a toxic or
metabolic disorder is suspected.
DIAGNOSTIC FINDINGS
*Computed Tomography (CT) scanning
*Magnetic Resonance Imaging (MRI)
*Electro-encephalography
*Less common procedure include
*Pistron Emission Tomography (PET)
*Single Photon Emission Computed Tomogrophy (SPECT)
*Laboratory tests include: analysis of blood glucose,
electrolytes,
serum ammonia,
liver function tests;
blood urea nitrogen levels;
serum osmolality;
calcium level,
COMPLICATIONS
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.
Pneumonia - common in patients receiving mechanical ventilation or in those
who cannot maintain and clear the airway.
Pressure ulcers - may become infected and serve as a source of sepsis.
Aspiration - aspiration of gastric contents or feedings may occur,
precipitating the development of aspiration pneumonia or airway occlussion.
MEDICAL MANAGEMENT
The first priority of treatment is to obtain and maintain a patent airway.
The patient may be orally or nasally intubated, or a tracheostomy may be performed.
Mechanical ventilator is used to maintain adequate oxygenation and ventilation.
The circulatory status (blood pressure and heart rate) is monitored to ensure adequate
perfusion to the body and brain.
An intravenous (IV) catheter is inserted to provide access for IV fluids and medications.
Neurologic care focuses on the specific neurologic pathology, if known.
Nutritional support, via a feeding tube or a gastrostomy tube, is initiated as soon as
possible
Other medical interventions are aimed at pharmacologic management and prevention of
complications
NURSING MANAGEMENT
To establish an adequate airway and ventilation
Position the patient in lateral or semiprone position; do not
allow the patient to remain on back
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
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
Enemas may be contraindicated if valsalva maneuver increase
intracranial pressure
Administer stool softeners and glycerin suppositories as
indicated
Reinforce and clarify information about patients
condition to permit family members to mobilize their own
adaptive capacities
Encourage ventilation of feelings and concerns
Support family in decision making process concerning
posthospital management and placement
To help patient to over come profound sensory
deprivation
Make efforts to maintain usual day and night patterns of
activity and sleep
Touch and talk to patient
Begin to teach activities of daily as soon as
consciousness returns
Support, encourage, and supervise patients effort
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
CLINIICAL MANIFESTATION
When ICP increases to the point where the brains 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.
CLINIICAL MANIFESTATION (contd)
CLevel of responsiveness and consciousness is the most important indicator of
the patients condition.
CLethargy is the earliest sign of increasing ICP. Slowing of speech and delay in
response to verbal suggestions are early indicators.
CSudden change in condition, such as restlessness (without apparent cause),
confusion, or increasing drowsiness, has neurologic significance.
CDecreased cerebral perfusion pressure (CPP) can result in a Cushings
response and Cushings triad (bradycardia, bradypnea, and hypertension);
widening pulse pressure us an ominous sign.
CAs 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.
CWhen coma is profound, pupils are dilated and fixed, respirations are impaired,
and death is usually inevitable.
ASSESSMENT AND DIAGNOSTIC METHODS
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.
ICP monitoring provides useful information (ventriculostomy, subarachnoid
bolt.screw, epidural monitor, fiberoptic monitor).
MEDICAL MANAGEMENT
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.
PHARMACOLOGIC THERAPY
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).
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).
Patient requires care in a critical care unit
NURSING MANAGEMENT
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ASSESSMENT
Obtain patient history with subjective data, including events leading to present
illness.
Complete a neurologic examination as patients condition allows.
Use the Glasgrow Coma Scale to assess verbal response, motor response, and eye
opening behaviors.
Note subtle changes, such as restlessness, headache, forced breathing, mental
cloudiness, and purposeless movements, which may be early indications of rising ICP.
Assess headache (usually constant, increasing in intensity, and aggravated by
movement or straining).
Note recurrent or projectile vomiting, which indicates increased pressure.
Monitor ICP closely as an essential part of management.
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.
NURSING MANAGEMENT
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 (Cushings
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.
DIAGNOSIS
Ineffective airway clearance related to accumulation of secretions
secondary to depressed level of responsiveness
Ineffective cerebral tissue perfusion related to effects of increased
ICP
Ineffective breathing patterns related to neurologic dysfunction
(brain stem compression, structural displacement)
Risk for fluid volume deficit related to dehydration procedures
Risk for infection related to ICP monitoring system (fiberoptic or
intraventricular catheter)
NURSING DIAGNOSES
DIAGNOSIS (contd)
Brain stem herniation
Diabetes insipidus
Syndrome of inappropriate antidiuretic hormone (SIADH) secretion
COLLABORATIVE PROBLEMS / POTENTIAL COMPLICATIONS
PLANNING OF GOALS
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.
NURSING INTERVENTION
Maintain patency of the airway; oxygenate patient before and after
suctioning.
Auscultate lung fields for adventitious sounds every 8 hours
Elevate head of bed to help clear secretions and improve venous
drainage of the brain.
Discourage coughing and straining
MAINTAINING A PATENT AIRWAY
NURSING INTERVENTION (contd)
cMonitor constantly for respiratory irregularities.
cCollaborate 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.
cMaintain continuous neurologic observation record with repeated
assessments.
ATTAINING NORMAL RESPIRATORY PATTERN
+Monitor for bradycardia, bradypnea, and rising blood pressure (Cushings
reflex or response)
+Avoid raising jugular venous pressure and ICP by keeping patients head in a
neutral (midline) position and maintaining slight elevation of the head to aid in
venous drainage.
+Avoid extreme rotation and flexion of the neck, because compression or
distortion of the jugular veins increases ICP.
+Avoid extreme hip flexion: this postion causes and increase in intra-abdominal
and intrathoracic pressures, which produce a rise in ICP.
+Instruct patient to exhale when moving or turning in bed to avoid the Valsalva
maneuver.
PRESERVING AND IMPROVING CEREBRAL TISSUE PERFUSION
+Provide stool softeners and a high-fiber diet if patient can eat; note any
abdominal distention.
+Avoid isometric muscle contractions.
+Avoid suctioning longer than15 seconds; hyperventilate on ventilator with
100% oxygen before suctioning.
+Maintain a calm atmosphere and reduce environmental stimuli; avoid
emotional stress.
+Avoid enemas and cathartics.
+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.
PRESERVING AND IMPROVING CEREBRAL TISSUE PERFUSION
(contd)
*Asses skin turgor, mucous membranes, and serum and urine
osmolality for signs for dehydration.
*Monitor vital signs to assess fluid volume status.
*Give oral hygiene for mouth dryness.
*Insert indwelling catheter to assess renal and fluid status.
*Monitor urine output every hour in the acute phase.
*Administer intravenous fluids by pump at a slow to moderate rate;
monitor patients receiving mannitol for congestive failure.
*Administer conrticosteriods and dehydrating agents as ordered.
*Test strools for blood if patient is on high doses of corticosteriods
(gastrointestinal bleeding is complication).
MAINTAINING NEGATIVE FLUID BALANCE
;Strictly adhere to the facilitys written protocols for managing ICP
monitoring systems.
;Keep dressing over ventricular catheters dry, because wet
dressings are conducive to bacterial growth.
;Use aseptic technique at all times when managing the ventricular
drainage system and changing drainage bag.
;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.
;Monitor for signs and symptoms of meningitis: fever, chills, nuchal
(neck) rigidity, and increasing or persistent headache.
PREVENTING INFECTION
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.
Impending brain herniation: monitor for increase in blood pressure,
decrease in pulse, and change in papillary response.
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.
Diabetes insipidus requires fluid and electrolyte replacement and
administration of vasopressin; monitor serum electrolytes for replacement.
SIADH requires fluid restriction and serum electrolyte monitoring.
MONITORING AND MANAGING POTENTION COMPLICATIONS
EVALUATION
EXPECTED PATIENT OUTCOMES
Remains free of excessive airways secretions; airways is patent
Attains normal respirations
Demonstrates improved cerebral tissue perfusion
Attains improved fluid balance
Has no sign of infection
Remains free of complications


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Seizure Disorder page 1

By: Erika Faye E. Docog

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