Focus on Stroke: Nursing Management

Stroke: Nursing ManagementZoya Minasyan, RN, MSN-EduStructures and Functions of Nervous System

Left hemisphere of cerebrum, lateral surface, showing major lobes and areas of the brain. 2Structures and Functions of Nervous System

Structural features of neurons: dendrites, cell body, and axons.3Structures and Functions of Nervous System

Major divisions of the central nervous system (CNS). 4Structures and Functions of Nervous System

The cranial nerves are numbered according to the order in which they leave the brain. 5Structures and Functions of Nervous System

Arteries of the head and neck. Brachiocephalic artery, right common carotid artery, right subclavianartery, and their branches. The major arteries to the head are the common carotid and vertebral arteries. 6Structures and Functions of Nervous System

Arteries at the base of the brain. The arteries that compose the circle of Willis are the two anteriorcerebral arteries joined to each other by the anterior communicating cerebral artery and to the posteriorcerebral arteries by the posterior communicating arteries.7Structures and Functions of Nervous System

The vertebral column (three views).8StrokeStroke occurs when ischemia or hemorrhage into the brain results in death of brain cells.Also known as a brain attackFunctions are lost or impairedSuch as movement, sensation, or emotions that were controlled by the affected area of the brain Severity of the loss of function varies according to the location and extent of the brain involved.

9The term brain attack communicates the urgency of recognizing the clinical manifestations of a stroke and treating a medical emergency, similar to what would be done with a heart attack.

Risk FactorsMost effective way to decrease the burden of stroke is prevention.Risk factors can be divided into non modifiable and modifiable risks.10Risk FactorsModifiableHypertensionMetabolic syndromeHeart diseaseHeavy alcohol consumptionPoor dietDrug abuse Sleep apneaObesityPhysical inactivitySmoking

Non modifiableAgeGenderRaceHeredity/family history

11Stroke risk increases with age, doubling each decade after 55 years of age. Two thirds of all strokes occur in individuals >65 years.Strokes are more common in men, but more women die from stroke than men. African Americans have a higher incidence of stroke as well as a higher death rate from stroke than whites.

Types of Stroke Strokes are classified on the basis of underlying pathophysiologic findings.IschemicThromboticEmbolicHemorrhagic 12Major Types of Stroke

13Ischemic StrokeIschemic strokes result from Inadequate blood flow to the brain from partial or complete occlusion of an artery80% of all strokes are ischemic strokes. Ischemic strokes can beThromboticEmbolic

14Ischemic StrokeThrombotic strokeThrombosis occurs in relation to injury to a blood vessel wall and formation of a blood clot.Result of thrombosis or narrowing of the blood vesselMost common cause of stroke Lacunar strokesa stroke from occlusion of a small penetrating artery with development of a cavity in the place of the infarcted brain tissue. thrombotic strokes are associated with hypertension or diabetes mellitus, both of which accelerate atherosclerosis

15Two thirds of thrombotic strokes are associated with hypertension or diabetes mellitus, both of which accelerate atherosclerosis. In 30% to 50% of individuals, thrombotic strokes have been preceded by a TIA. Most patients with ischemic stroke do not have a decreased level of consciousness in the first 24 hours, unless it is due to a brainstem stroke or other conditions such as seizures, increased ICP, or hemorrhage. A lacunar stroke refers to a stroke from occlusion of a small penetrating artery with development of a cavity in the place of the infarcted brain tissue. This most commonly occurs in the basal ganglia, thalamus, internal capsule, or pons. Pathogenesis of Atherosclerosis

A, Damaged endothelium.B, Diagram of fatty streak and lipid core formation.C, Diagram of fibrous plaque. Raised plaques are visible: some are yellow, others are white.D, Diagram of complicated lesion: thrombus is red, collagen is blue. Plaque is complicated by red thrombus deposition. A, Damaged endothelium.B, Diagram of fatty streak and lipid core formation.C, Diagram of fibrous plaque. Raised plaques are visible: Some are yellow, others are white.D, Diagram of complicated lesion: Thrombus is red, collagen is blue. Plaque is complicated by red thrombus deposition. 16Pathogenesis of AtherosclerosisDevelopmental stages: Fatty streaksEarliest lesionsCharacterized by lipid-filled smooth muscle cellsPotentially reversible Fibrous plaque Beginning of progressive changes in the arterial wallLipoproteins transport cholesterol and other lipids into the arterial intima. Fatty streak is covered by collagen, forming a fibrous plaque that appears grayish or whitish.Result = Narrowing of vessel lumen Complicated lesion Continued inflammation can result in plaque instability, ulceration, and rupture.Platelets accumulate and thrombus forms. Increased narrowing or total occlusion of lumen

17These changes can appear in the coronary arteries by age 30 and can increase with age.

Ischemic StrokeEmbolic strokeOccurs when an embolus lodges in and occludes a cerebral arteryResults in infarction and edema of the area supplied by the involved vesselSecond most common cause of strokePatient with an embolic stroke commonly has a rapid occurrence of severe clinical symptoms.Onset of embolic stroke is usually sudden and may or may not be related to activity.Patient usually remains conscious, although he may have a headache.

18Ischemic StrokeTransient ischemic attackTransient episode of neurologic dysfunction caused by focal brain, spinal cord, or retinal ischemia, without acute infarction of the brain Symptoms last 3 cm

After stroke has stabilized for 12 to 24 hours, collaborative care shifts from preserving life to lessening disability and attaining optimal functioning.Patient may be transferred to a rehabilitation unit, outpatient therapy, or home carebased rehabilitation.

54Merci Embolus Retriever in Cerebral Ischemic StrokeThe MERCI retriever removes blood clots in patients who are experiencing ischemic strokes. Theretriever is a long, thin wire that is threaded through a catheter into the femoral artery. The wire is pushed through the end of the catheter up to the carotid artery. The wire reshapes itself into tiny loops that latch onto the clot and the clot can then be pulled out. To prevent the clot from breaking off, a balloon at the end of the catheter inflates to stop blood flow through the artery.

55The MERCI retriever removes blood clots in patients who are experiencing ischemic strokes. The retriever is a long, thin wire that is threaded through a catheter into the femoral artery. The wire is pushed through the end of the catheter up to the carotid artery. The wire reshapes itself into tiny loops that latch onto the clot, and the clot can then be pulled out. To prevent the clot from breaking off, a balloon at the end of the catheter inflates to stop blood flow through the artery.Clipping and Wrapping of Aneurysms

56GDC Coil: Gugleilmi detachable coils

A, A coil is used to occlude an aneurysm. Coils are made of soft, spring like platinum. The softness of the platinum allows the coil to assume the shape of irregularly shaped aneurysms while posing little threat of rupture of the aneurysm. B, A catheter is inserted through an introducer (small tube) in an artery in the leg. The catheter is threaded up to the cerebral blood vessels. C, Platinum coils attached to a thin wire are inserted into the catheter and then placed in the aneurysm until the aneurysm is filled with coils. Packing the aneurysm with coils prevents the blood from circulating through the aneurysm, reducing the risk of rupture. 57Nursing ManagementNursing Assessment If the patient is stable, obtainDescription of the current illness with attention to initial symptomsHistory of similar symptoms previously experiencedCurrent medications History of risk factors and other illnessesFamily history of stroke or cardiovascular disease

58Subjective and objective data that should be obtained from a person who has had a stroke are presented in Table 58-7.

Nursing ManagementNursing AssessmentComprehensive neuro examinationLevel of consciousnessCognitionMotor abilitiesCranial nerve functionSensation Deep tendon reflexes

59Nursing ManagementNursing DiagnosesRisk for ineffective cerebral tissue perfusionIneffective airway clearance Impaired physical mobilityImpaired verbal communicationImpaired urinary elimination Impaired swallowingSituational low self-esteem

60Nursing ManagementPlanningGoals are that the patient willMaintain stable or improved level of consciousnessAttain maximum physical functioningMaximize self-care abilities and skillsMaintain stable body functionsMaximize communication abilities. Avoid complications of stroke. Maintain effective personal and family coping.

61Nursing ManagementNursing ImplementationHealth promotionTo reduce the incidence of stroke, the nurse should focus teaching toward stroke prevention.Particularly in persons with known risk factorsEducation about hypertension control and adherence to medicationTeaching patients and families about Early symptoms StrokeTIA When to seek health care for symptoms

62Nursing measures to reduce risk factors for stroke are similar to those for coronary artery disease.Uncontrolled hypertension is the primary cause of stroke. The nurse will need to be an advocate for the monitoring and management of hypertension, including assessing financial need and prescription coverage.

Nursing ManagementNursing ImplementationRespiratory systemManagement of the respiratory system is a nursing priority.Risk for atelectasisRisk for aspiration pneumoniaRisks for airway obstructionMay require tracheal intubation and mechanical ventilation 63Advancing age and immobility increase the risk for atelectasis and pneumonia. Risk for aspiration pneumonia is high because of impaired consciousness or dysphagia. All patients should be effectively screened for their ability to swallow and kept NPO until dysphagia has been ruled out.Nursing interventions to support adequate respiratory function are individualized to meet the needs of the patient (include frequent assessment of airway patency and function, oxygenation, suctioning, patient mobility, positioning of the patient to prevent aspiration, and encouraging deep breathing).Interventions related to maintenance of airway function are described in NCP 58-1.

Nursing ManagementNursing ImplementationNeurologic systemMonitor closely to detect changes suggesting Extension of the stroke ICPVasospasmRecovery from stroke symptoms Table 58-8, page 1472 the NIH Stroke Scale (NIHSS)national institutes of health stroke scale .

64Nursing Management: Nursing ImplementationCardiovascular systemGoals aimed at maintaining homeostasisMany patients with stroke have decreased cardiac reserves from the secondary diagnoses of cardiac disease. Monitoring vital signs frequently Monitoring cardiac rhythmsCalculating intake and output, noting imbalancesRegulating IV infusions Adjusting fluid intake to the individual needs of the patientMonitoring lung sounds for crackles and rhonchi (pulmonary congestion)Monitoring heart sounds for murmursAfter stroke, patient is at risk for deep vein thrombosis.Related to immobility, loss of venous tone, and muscle pumping in legMost effective prevention is keeping the patient moving.

65Nursing ManagementNursing ImplementationMusculoskeletal systemGoal is to maintain optimal function. prevention of joint contractures and muscular atrophyrange-of-motion exercises and positioning are important.Paralyzed or weak side needs special attention when positioned. Avoidance of pulling the patient by the arm to avoid shoulder displacement Hand splints to reduce spasticity

66Passive range-of-motion exercise is begun on the first day of hospitalization. If the stroke is due to subarachnoid hemorrhage, movement is limited to the extremities. Specific deformities on the weak or paralyzed side that may be present in patients with stroke include internal rotation of the shoulder; flexion contractures of the hand, wrist, and elbow; external rotation of the hip; and plantar flexion of the foot.

Nursing ManagementNursing ImplementationIntegumentary system Susceptible to breakdown related to Loss of sensationDecreased circulationImmobilityCompounded by patient age, poor nutrition, dehydration, edema, and incontinence Pressure relief by position changes, special mattresses, or wheelchair cushionsGood skin hygieneEarly mobilityPosition patient on the weak or paralyzed side for only 30 minutes.

67Nursing Management Nursing ImplementationGastrointestinal systemStress of illness.Constipation. Patients may be placed on stool softeners.Physical activity promotes bowel function.

Urinary systempromote normal bladder function. Avoid the use of indwelling catheters.

68If the patient does not have a daily or every-other-day bowel movement, check the patient for impaction. The patient who has liquid stools should also be checked for stool impaction. Depending on the patients fluid balance status and swallowing ability, fluid intake should be at least 1800 to 2000 mL/day and fiber intake up to 25 g/day.

Nursing ManagementNursing ImplementationNutrition Nutritional needs require quick assessment and treatment.May initially receive IV infusions to maintain fluid and electrolyte balanceMay require nutritional supportFirst feeding should be approached carefully.Test swallowing, chewing, gag reflex, and pocketing before beginning oral feeding.Feedings must be followed by oral hygiene.

69Nursing ManagementNursing ImplementationCommunicationNurses role in meeting psychologic needs of the patient is primarily supportive. Patient is assessed for both the ability to speak and the ability to understand.Speak slowly and calmly, using simple words or sentences.Gestures may be used to support verbal cues. 70Nursing ManagementNursing ImplementationSensory-perceptual alterationsBlindness in same half of each visual field is a common problem after stroke.Known as homonymous hemi anopsiaA neglect syndrome (decrease in safety, increase risk for injury)Other visual problems may include Diplopia (double vision)Ptosis (drooping eyelid)71Homonymous Hemianopsia (Food on left side is not seen)

Spatial and perceptual deficits in stroke. Perception of a patient with homonymous hemi anopsiaShows that food on the left side is not seen and thus is ignored.72Nursing ManagementNursing ImplementationCopingAffects family EmotionallySociallyFinancially Changing roles and responsibilitiesExplain What has happenedDiagnosisTherapeutic procedures Should be clear and understood by patient. social services referral is often helpful.

73During the acute phase of caring for the stroke patient and the family, nursing interventions designed to facilitate coping involve providing information and emotional support.

Nursing Management: Nursing ImplementationAmbulatory and home carePatient is usually discharged to home, an intermediate or long-term care facility, or a rehabilitation facility.discharge planning with the patient and family starts early in the hospitalization and promotes a smooth transition from one care setting to another. prepare the patient and family for discharge throughEducation DemonstrationPracticeEvaluation of self-care skills Rehabilitation to promote optimal functioning.Physical, mental, and social well-being

74Loss of Postural Stability

Loss of postural stability is common after stroke. The patient is unable to sit upright and tends to fall sideways. Appropriate support with pillows or cushions should be provided.75Nursing ManagementNursing ImplementationAmbulatory and home care (contd)Musculoskeletal interventionsBalance trainingTransferring from bed to chairBobath method Therapists and nurses use the Bobath approach to encourage normal muscle tone, normal movement, and promotion of bilateral function of the body. An example is to have the patient transfer into the wheelchair using the weak or paralyzed side and the stronger side to facilitate more bilateral functioning. CIMT is a more recent approach. Constraint-induced movement therapy (CIMT) encourages the patient to use the weakened extremity by restricting movement of the normal extremity. This approach is challenging, and the ability of patients to comply may limit its use.

76Nursing ManagementNursing ImplementationAmbulatory and home care (contd)After acute phase, a dietitian can assist in determining appropriate daily caloric intake based on the patientsSizeWeightActivity level Nurse and speech therapist must assess ability of patient to swallow solids and fluids and must adjust the diet appropriately. Inability to feed oneself can be frustrating and may result in malnutrition and dehydration.

77Assistive Devices for Eating

A, The curved fork fits over the hand. The rounded plate helps keep food on the plate. Special grips are helpful for some persons. B, Knives with rounded blades are rocked back and forth to cut food. The person does not need a fork in one hand and a knife in the other. C, Plate guards help keep food on the plate. D, Cup with special handle.A, The curved fork fits over the hand. The rounded plate helps keep food on the plate. Special grips and swivel handles are helpful for some persons. B, Knives with rounded blades are rocked back and forth to cut food. The person does not need a fork in one hand and a knife in the other. C, Plate guards help keep food on the plate. D, Cup with a special handle. 78Nursing ManagementNursing ImplementationImplement a bowel management program for problems with Bowel controlConstipationIncontinenceHigh-fiber diet and adequate fluid intake

79Patients with stroke frequently have constipation, which responds to the following dietary management:Fluid intake of 2500 to 3000 mL daily unless contraindicatedPrune juice (120 mL) or stewed prunes dailyCooked fruit 3 times dailyCooked vegetables 3 times dailyWhole-grain cereal or bread 3 to 5 times daily

Nursing ManagementNursing ImplementationPatients with stroke on right side of brainDifficulty in judging position, distance, and movementImpulsive, impatient, and denying problems related to strokeRespond best to directions given verballyPatients with stroke on left side of brainSlower in organization and performance of tasksImpaired spatial discriminationHave fearful, anxious response to strokeRespond well to nonverbal cues

80Nursing ManagementNursing ImplementationInterventions for atypical emotional responseDistract the patient.Explain that emotional outbursts may occur.Maintain a calm environment.Avoid shaming.

Patients with a stroke may be coping with many lossesOften go through the process of griefSome patients experience long-term depressionSupport communication between the patient and family.Discuss lifestyle changes.Discuss changing roles within the family. Be an active listener.Include family in goal planning and patient care.Support family conferences.

81Nursing ManagementNursing ImplementationFamily members must cope with Recognition of behavioral changes resulting from neurologic deficits that are not changeable Responses to multiple losses by both the patient and the family.Behaviors that may have been reinforced during the early stages of stroke as continued dependency

Stroke support groups within rehab facilities and community are helpful.Mutual sharingEducationCopingUnderstanding

82Nursing ManagementNursing ImplementationSpeech, comprehension, and language deficits are the most difficult problem for the patient and family.Speech therapists can assess and formulate a plan to support communication.Nurses can be a role model for patients with aphasia.83A patient with right-sided paresthesias and hemiparesis is hospitalized and diagnosed with a thrombotic stroke. Over the next 72 hours, the nurse plans care with the knowledge that the patient:

1. Is ready for aggressive rehabilitation.2. Will show gradual improvement of the initial neurologic deficits.3. May show signs of deteriorating neurologic function as cerebral edema increases.4. Should not be turned or exercised to prevent extension of the thrombus and increased neurologic deficits. Question #1843Rationale: Ischemic stroke symptoms may progress in the first 72 hours as infarction and cerebral edema increase.While performing health screening at a health fair, the nurse identifies which of the following individuals at greatest risk for experiencing a stroke?

1. A 46-year-old white female with hypertension and oral contraceptive use for 10 years.2. A 58-year-old white male salesman who has a total cholesterol level of 285 mg/dL.3. A 42-year-old African American female with diabetes mellitus who has smoked for 30 years.4. A 62-year-old African American male with hypertension who is 35 pounds overweight. Question #285Answer: 4Rationale: Option 4: This individual has five risk factors: age, African American, male, hypertension, and overweight. Option 1: This individual has two risk factors: hypertension and oral contraception use. Option 2: This individual has two risk factors: male and increased cholesterol level. Option 3: This individual has three risk factors: African American, diabetes mellitus, and smoking.Nonmodifiable risk factors include age, gender, ethnicity/race, and family history/heredity. Stroke risk increases with age, doubling each decade after 55 years of age. Two thirds of all strokes occur in individuals >65 years. Strokes are more common in men, but more women die from stroke than men. Because women tend to live longer than men, they have more opportunity to suffer a stroke. African Americans have a higher incidence of stroke, as well as a higher death rate from stroke than whites. A family history of stroke, a prior transient ischemic attack, or a prior stroke also increases the risk of stroke. Modifiable risk factors are those that can potentially be altered through lifestyle changes and medical treatment, thus reducing the risk of stroke. Modifiable risk factors include hypertension, increased cholesterol, elevated blood lipid levels, heart disease, smoking, excessive alcohol consumption, obesity, sleep apnea, metabolic syndrome, lack of physical exercise, poor diet, and drug abuse.Early forms of birth control pills that contained high levels of progestin and estrogen increased a womans chance of experiencing a stroke, especially if she also smoked heavily. Newer, low-dose oral contraceptives have lower risks for stroke except in those individuals who are hypertensive and smoke. Other conditions that may increase stroke risk include migraine headaches, inflammatory conditions, and hyperhomocysteinemia. Sickle cell disease is another known risk factor for stroke.Answer #2Answer: 4Rationale: Option 4: This individual has five risk factors: age, African American, male, hypertension, and overweight. Option 1: This individual has two risk factors: hypertension and oral contraception use. Option 2: This individual has two risk factors: male and increased cholesterol level. Option 3: This individual has three risk factors: African American, diabetes mellitus, and smoking.

Answer #2Nonmodifiable risk factors include age, gender, ethnicity/race, and family history/heredity. Stroke risk increases with age, doubling each decade after 55 years of age. Two thirds of all strokes occur in individuals >65 years. Strokes are more common in men, but more women die from stroke than men. Because women tend to live longer than men, they have more opportunity to suffer a stroke. African Americans have a higher incidence of stroke, as well as a higher death rate from stroke than whites. A family history of stroke, a prior transient ischemic attack, or a prior stroke also increases the risk of stroke. Modifiable risk factors are those that can potentially be altered through lifestyle changes and medical treatment, thus reducing the risk of stroke. Modifiable risk factors include hypertension, increased cholesterol, elevated blood lipid levels, heart disease, smoking, excessive alcohol consumption, obesity, sleep apnea, metabolic syndrome, lack of physical exercise, poor diet, and drug abuse.Early forms of birth control pills that contained high levels of progestin and estrogen increased a womans chance of experiencing a stroke, especially if she also smoked heavily. Newer, low-dose oral contraceptives have lower risks for stroke except in those individuals who are hypertensive and smoke. Other conditions that may increase stroke risk include migraine headaches, inflammatory conditions. Sickle cell disease is another known risk factor for stroke.

A patient with a stroke has dysphagia. Before allowing the patient to eat, which of the following actions should the nurse take first?

1. Check the patients gag reflex.2. Request a soft diet with no liquids.3. Place the patient in high-Fowlers position.4. Test the patients ability to swallow with a small amount of water. Question #388Answer: 1Rationale: Before initiation of feeding, assess the gag reflex by gently stimulating the back of the throat with a tongue blade. If a gag reflex is present, the patient will gag spontaneously. If it is absent, defer the feeding, and begin exercises to stimulate swallowing. To assess swallowing ability, elevate the head of the bed to an upright position (unless contraindicated), and give the patient a small amount of crushed ice or ice water to swallow.Answer #3

Answer: 1Rationale: Before initiation of feeding, assess the gag reflex by gently stimulating the back of the throat with a tongue blade. If a gag reflex is present, the patient will gag spontaneously. If it is absent, defer the feeding, and begin exercises to stimulate swallowing. To assess swallowing ability, elevate the head of the bed to an upright position (unless contraindicated), and give the patient a small amount of crushed ice or ice water to swallow.

Case Study 73-year-old man was admitted to the hospital with right-sided paresis and expressive aphasia.He had been experiencing periods of confusion, right-sided weakness, and slurred speech for the past several weeks. These episodes were brief and resolved completely within an hour. No treatments were sought.

90Case Study 1History of COPD, MI 15 years prior, and atrial fibrillation

Over the first 24 hours of admission, his neurologic deficits gradually progressed.

By day 2 of admission, he had right-sided flaccid paralysis and global aphasia.

91Discussion Questions Case Study What is probably the cause of his stroke?

Could this stroke have been prevented?

With his history of atrial fibrillation, he could have had an embolic stroke. He also has risk factors for a thrombotic stroke. He also could have been having transient ischemic attacks.There are preventable risk factors that could have been modified, such as hypertension. The atrial fibrillation should have been treated with anticoagulants.

92Discussion Questions Case Study What are the priority nursing interventions for him?

What teaching will you need to do for him and his family?

3. Preventing any complications related to immobility. Helping him adjust and cope with the results of the stroke.4. Discuss what changes they can expect to see as a result of the stroke. Then the focus should be on rehabilitation.

93Seizure DisordersSeizures are abrupt, uncontrolled electrical brain discharges that cause alteration in level of consciousness and changes in motor and sensory behavior.Epilepsy is a group of syndrome characterized by recurring seizures. - it can be idiopathic or secondary caused by conditions such as brain tumor, acute alcohol withdrawal, and electrolyte imbalance. - it is not associated with alterations in intellectual capabilities.* SeizuresAre classified as neurologic emergency. Sustained untreated seizures can result to hypoxia, cardiac dysrhythmias, and lactic acidosis.Risk Factors/Contributing Factors - Genetic predisposition - Acute febrile state - Head trauma - Cerebral edema -Abrupt cessation of antiepileptic drugs (AEDs) -Infections - Metabolic Disorder (hypoglycemia) - Exposure to toxins - Brain Tumor - Hypoxia - Alcohol withdrawal- Fluid and electrolyte imbalances. Increased physical activityStressFatigueCaffeineDiagnostics ProceduresElectroencephalogram (EEG) records electrical activity and identifies the origin of seizure activity. Client instructions include: Wash hair before the procedure ( no oils or spray) and after the procedure ( to remove electrode glue)Maybe asked to take deep breaths and/or be exposed to flashes of light during the test.Sleep may be with held prior to test and possibly induced during test.Blood and urine culture test, MRI, CT, CSF analysis, skull x-ray, electrolyte profile and drug screen may all be used to identify or rule out potential causes of seizures. Assessments:Assess and monitor: - Airway patency - Aspiration - Injury post seizure - If client experienced an aura ( warning sensation), possible indication of the origin of seizure. - Possible trigger factor ( e.g. fatigue).

Nursing InterventionsProtect the client from injury ( e.g move furnitures away).Maintain a patent airway.Be prepared to suctionTurn the pt to the side ( decreased the risk for aspiration)Loosen clothing.Do not attempt to restrain the client.Do not attempt to open jaw during seizure activity (may damage the teeth, lips, and tongue). Do not use padded tongue blades.Administer oxygen as prescribed.Administer prescribed medications. ( anticonvulsants and sedatives).Usual medications prescribed : anticonvulsants Keppra, Tegretol, Dilantin, Depakene/Depakote, Phenobarbital sedatives Valium ( Diazepam), Ativan (Lorazepam)Document onset and duration of seizure and client findings/observations prior to during, and following the seizure (level of consciousness), apnea, cyanosis, motor activity, incontinenence).Post Seizure Nursing ManagementMaintain the client in a side-lying position to prevent aspiration and to facilitate drainage of oral secretions.Check Vital signs including O2 saturation level.Perform neurological checks.Reorient and calm the client (maybe agitated).Institute seizure precautions.Provide client education regarding seizure management.maintain therapeutic medication levels.Possible drug interactions (e.g. decreased effectiveness of oral contraceptives.Encourage the client to wear medical alert bracelet (necklace) at all times.

Seizure PrecautionsStandby Oxygen, airway and suctioning equipment.IV access ( medication administration- drug for seizure) Side rails in up position and bed at lowest position.Padded side rails to prevent injury to client.

* Complications and Nursing Implications

AspirationTurn the client to side, suction as needed.Status epilepticus potential complication of all seizure disorders. - Establish airway, provide oxygen, ensure IV access, perform EKG monitoring and monitor ABG results. - As prescribed administer Diazepam or Lorazepam and a loading dose following by a continuous infusion of Phenytoin ( Dilantin) * Dilantin can cause gingival hyperplasia, therefore monitor for gingival inflammation and instruct client to use soft bristle toothbrush. Monitor and report gum bleeding if noted.

Glasgow Coma Scale (GCS)Glasgow Coma ScaleThe Glasgow Coma Scale provides a score in the range 3-15; patients with scores of 3-8 are usually said to be in a coma. The total score is the sum of the scores in three categories. For adults the scores are as follows:Eye Opening Response - Spontaneous--open with blinking at baseline 4 points - Opens to verbal command, speech, or shout 3 points - Opens to pain, not applied to face 2 points - None 1 point Verbal Response - Oriented 5 points - Confused conversation, but able to answer questions 4 points - Inappropriate responses, words discernible 3points - - Incomprehensible speech 2 points - None 1point Motor Response - Obeys commands for movement 6points - Purposeful movement to painful stimulus 5 points - Withdraws from pain 4 points - Abnormal (spastic) flexion, decorticate posture 3 points - Extensor (rigid) response, decerebrate posture 2 points - None 1 pointGlasgow Coma ScaleInterpretationGenerally, brain injury is classified as:Severe, with GCS 8Moderate, GCS 9 - 12Minor, GCS 13.