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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

Seizure





CLASSIFICATION

Generalized absence (petit mal)

Generalized tonic-clonic (grand mal)Myolonic

Atonic

Generalized seizures

Partial seizures (focal seizures)

Simple partial

Complex partial

Seizure





Seizure

CLASSIFICATION

Partial seizures (focal seizures)





Seizure

CLASSIFICATION Generalized seizures





CLASSIFICATION Unclassified seizuresTYPE 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

Seizure


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Seizure

CLASSIFICATION Unclassified seizures (cont’d)





CLASSIFICATION Unclassified seizures (cont’d) TYPE DESCRIPTION SIGNS AND SYMPTOMS

GENERALIZED

CLONIC - Opposing muscles contract andrelax 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

Seizure





Seizure

CLASSIFICATION Unclassified seizures (cont’d)






GENERALIZED

ATONICDrop and fall attack;

Needs to wear protected helmetLoss of posture tone

AKINETICSudden brief loss of muscle tone or

postureTemporary loss of consciousness

Seizure






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

Seizure






UNCLASSIFIED

FEBRILE - Seizure threshold lowered byelevated 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

Seizure





CAUSES

Seizure





Seizure

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

Seizure





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

Seizure





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)

Seizure





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

Seizure





NURSING CARE DURING SEIZURE (cont’d)

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

Seizure





Seizure





Seizure

A generalized tonic clonic seizure. Here thewhole 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

Seizure





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

Seizure





DEFINITION

Status Epilepticus

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 timerecurring seizures occur

The attack is usually related to failure to take prescribed anticonvulsants





CAUSES

Status Epilepticus

o Perinatal hypoxia or anoxia that injures the brain

o Meningitis

o Metabolic disorder

In infants

In adults

o Infections of the brain,

o Strokeso Brain tumors

o Severe head trauma





PATHOPHYSIOLOGY

Status Epilepticus

The exact pathophysiology of why seizure

evolves into status

is complex and not fully understood





DIAGNOSTIC FINDINGS

Status Epilepticus

EEG – to monitor response to treatment

BLOOD TEST – glucose, electrolytes, liver functions

and illicit substances





MEDICAL MANAGEMENT

Status Epilepticus

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 (cont’d)

Status Epilepticus

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

Status Epilepticus

Initiates ongoing assessment and monitoring of respiratory and cardiac

functioning

Monitoring and documenting the seizure activity and the patient’s

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

Status Epilepticus

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

Epilepsy

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

Epilepsy

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

Epilepsy

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

http://www.kidshealth.org/teen/diseases_conditions/cancer/types_of_cancer.html

http://www.kidshealth.org/teen/drug_alcohol/alcohol/alcohol.html

http://www.kidshealth.org/teen/drug_alcohol/alcohol/alcohol.html









Epilepsy

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)





Epilepsy





DIAGNOSTIC FINDING:

Epilepsy

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 bysecond — 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: (cont’d)

Epilepsy

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

Epilepsy

Intravenous diazepam, lorazepam, or fosphenytoin isadministered 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 (cont’d)

Epilepsy

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

Epilepsy

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 basisand 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 andrest

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 (cont’d)

Epilepsy

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






Epilepsy

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 toavoid 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

Headache





COMMON

LOCATIONS OF

HEADACHE PAIN

Headache





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





Headache

TYPES OF HEADACHE





Headache

TYPES OF HEADACHE

Headache





TYPES OF HEADACHE

Composite drawing of two common methodsof ICP monitoring

(A) Iintra-ventricular catheter

(B) Subarachnoid bolt

Headache





TYPES OF HEADACHE

Headache





TYPES OF SURGICAL PROCEDURES

Headache





Headache





TYPES OF HEADACHE

1. Primary Headache

no organic cause can be identified

include migraine, tension type (muscle contraction), and cluster headaches

Headache





Strongly hereditary

More common in women

Tend to occur with stress or life crisis

Lasts for hour or daysOne side of the head is more affected than the other

TYPES OF HEADACHE

1. Primary headache

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

Headache





A. MIGRAINE HEADACHE

KINDS OF MIGRAINE (cont’d)

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

Headache





CAUSE AND SYMTOMS

CAUSE

SYMTOMS

dilatation of blood

vessels

a. nausea and vomiting

b. chills

c. fatigued. irritability

e. sweating

f. edema

Headache





CAUSE AND SYMTOMS

Headache





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

Headache





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


Headache





2. AURA PHASE (cont’d)

other symptoms include:

@numbness and tingling of the lips, face or hands

@mild confusion

@slight weakness of an extremity

@drowsiness

@dizziness


Headache





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


Headache





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


Headache





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

Headache





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 medicalconditions 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

Headache





TREATMENT (cont’d)

chocolate,

nuts,

onions,

cow’s milk,

wheat,

egg,

orange,

benzoic acid,

cheese,

tomato

AVOID FOODS LIKE:

Headache



Seizure Disorder page 76By: Erika Faye E. Docog

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 (cont’d)

Headache




SYMTOMS AND TREATMENT

SYMPTOMS

TREATMENT

sustained contraction of

head and neck muscles

Non narcotic analgesics

Relaxation technique

Amitriptyline

Headache




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 monthsIntense, 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


Headache





SYMPTOMS

TREATMENT

Flushing

Tearing of eyes

Nasal stuffiness

Sweating

Swelling of temporal

vessels

Narcotic analgesic I.M. during acute phase

100% oxygen by face mask for 15 minutes

ergotamine tartrate

sumatripan

Steroids

Percutaneous sphenopalatine ganglion

blockade

Headache




Cause of headache in older population, reaching its greatest incidence in

those older than 70 years old

TYPES OF HEADACHE


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

Headache




TYPES OF HEADACHE (cont’d)

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

Headache




ASSESSMENT

Detailed history and physical assessment

Data obtained for the health history should reflect patient’s own words

Focus health history on assessment of headache (location, quality,

frequency, precipitating factors, time, associated symptoms)

Headache




DIAGNOSTIC EVALUATION

Use to detect underlying cause such as tumor or aneurysm

CT Scan

Cerebral angiography

MRI

EMG – reveal a contraction of the neck, scalp, or facial muscles

Laboratory Test CBC

erythrocyte sedimentation rateelectrolytes

glucose

creatinine

thyroid hormone level

Headache




FACTORS PRECIPITATING HEADACHE

Emotional problems

Stress

Sleep patterns

Recreational interest

Appetite

Family stressors

Headache




NURSING MANAGEMENT

To enhance pain relief

To treat the acute event of the headache

To prevent recurrent episodes

Headache





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

Headache





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

o Altered 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 patient’s state of alertness and consciousness decreases, change will

ultimately occur in the pupillary response, eye opening response, verbalresponse, 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 FINDINGSComputed 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 protectthe 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 MANAGEMENTThe 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 patient’s

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 asconsciousness returns

Support, encourage, and supervise patient’s effort




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





CLINIICAL MANIFESTATION

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.





CLINIICAL MANIFESTATION (cont’d) Level of responsiveness and consciousness is the most important indicator of the patient’s condition.

Lethargy is the earliest sign of increasing ICP. Slowing of speech and delay in

response to verbal suggestions are early indicators.

Sudden change in condition, such as restlessness (without apparent cause),

confusion, or increasing drowsiness, has neurologic significance.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.

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.

When 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 T

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ASSESSMENT

Obtain patient history with subjective data, including events leading to present

illness.

Complete a neurologic examination as patient’s condition allows.

Use the Glasgrow Coma Scale to assess verbal response, motor response, and eyeopening 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 (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.





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 (cont’d)

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 (cont’d)

Monitor constantly for respiratory irregularities.

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.

Maintain continuous neurologic observation record with repeated

assessments.

ATTAINING NORMAL RESPIRATORY PATTERN






Monitor for bradycardia, bradypnea, and rising blood pressure (Cushing’s

reflex or response)

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.

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-abdominaland 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

(cont’d)






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 facility’s 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 andcontamination 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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