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Seizure Disorder page 1By: Erika Faye E. Docog
Dr. Anthony P. Toledo
MSNET2
Seizure Disorder page 2By: Erika Faye E. Docog
DEFINITION
Involuntary muscle contractions
caused by abnormal discharged of
electrical impulses from nerve cells
Seizure
Seizure Disorder page 3By: Erika Faye E. Docog
CLASSIFICATION
Generalized absence (petit mal)Generalized tonic-clonic (grand mal)MyolonicAtonic
Generalized seizures
Partial seizures (focal seizures)
Simple partialComplex partial
Seizure
Seizure Disorder page 4By: Erika Faye E. Docog
SeizureCLASSIFICATION
Partial seizures (focal seizures)
Seizure Disorder page 5By: Erika Faye E. Docog
SeizureCLASSIFICATION
Generalized seizures
Seizure Disorder page 6By: Erika Faye E. Docog
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
Seizure
Seizure Disorder page 7By: Erika Faye E. Docog
SeizureCLASSIFICATION
Unclassified seizures (cont’d)
Seizure Disorder page 8By: Erika Faye E. Docog
CLASSIFICATION Unclassified seizures (cont’d)
TYPE DESCRIPTION SIGNS AND SYMPTOMS
GENERALIZED
CLONIC - Opposing muscles contract and relax alternately in rhythmic pattern;
- May occur in one limb more than others
- Mucus production
TONIC Muscles are maintained in continuous contracted state (rigid posture)
- Variable loss of consciousness;- Pupils dilate;- Eyes roll up;- Glottis closes;- Possible incontinence;- May foam at mouth
TONIC-CLONIC (grand mal, major motor)
Violent total body seizure - Aura;- Tonic first(20 – 40 seconds);- Clonic next;- Postictal symptoms
Seizure
Seizure Disorder page 9By: Erika Faye E. Docog
SeizureCLASSIFICATION
Unclassified seizures (cont’d)
Seizure Disorder page 10By: Erika Faye E. Docog
CLASSIFICATION Unclassified seizures (cont’d)
TYPE DESCRIPTION SIGNS AND SYMPTOMS
GENERALIZED
ATONIC Drop and fall attack;Needs to wear protected helmet
Loss of posture tone
AKINETIC Sudden brief loss of muscle tone or
postureTemporary loss of consciousness
Seizure
Seizure Disorder page 11By: Erika Faye E. Docog
CLASSIFICATION Unclassified seizures (cont’d)
TYPE DESCRIPTION SIGNS AND SYMPTOMS
PARTIAL
SIMPLE PARTIAL Symptoms confined to one hemisphere
- May have motor (change in posture),
- Sensory (hallucinations);- Autonomic (flushing, tachycardia)
symptoms;- No loss of consciousness
COMPLEX PARTIAL Begins in one focal area, but spreads to both hemispheres (more common in adult)
- Loss of consciousness;- Aura of visual disturbances;- Postictal symptoms
Seizure
Seizure Disorder page 12By: Erika Faye E. Docog
CLASSIFICATION Unclassified seizures (cont’d)
TYPE DESCRIPTION SIGNS AND SYMPTOMS
UNCLASSIFIED
FEBRILE - Seizure threshold lowered by elevated temperature;
- Only one seizure per fever;- Common in 4% of population under
age 5;- Occurs when temperature is rapidly
rising
-Lasts less than 5 minutes;- Generalized;- Transient and nonprogressive;- Doesn’t generally result in brain
damage;- EEG is normal after 2 weeks
STATUS EPILEPTICUS Prolonged and frequent repetition of seizures without interruption; results in anoxia and cardiac and respiratory arrest
- Consciousness not regained between seizures;
- Lasts more than 30 minutes
Seizure
Seizure Disorder page 13By: Erika Faye E. Docog
CAUSES
Idiopathic origin
Head injury
Hypoglycemia
Brain tumor
Infection
Anoxia
Cerebrovascular disease – leading cause of seizure in elderly
Seizure
Seizure Disorder page 14By: Erika Faye E. Docog
SeizurePATHOPHYSIOLOGY
Many neurons fire in a synchronous pattern, resulting in a
transient physiologic disturbance
Physiologic disturbances include abnormal movements, abnormal
sensations and change in LOC
Seizure Disorder page 15By: Erika Faye E. Docog
ASSESSMENT FINDINGS
Aura
LOC
Dyspnea
Fixed and dilated pupil
Incontinence
Seizure
Seizure Disorder page 16By: Erika Faye E. Docog
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
Seizure Disorder page 17By: Erika Faye E. Docog
MEDICAL MANAGEMENTDiet: 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
Seizure Disorder page 18By: Erika Faye E. Docog
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
Seizure Disorder page 19By: Erika Faye E. Docog
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 Disorder page 20By: Erika Faye E. Docog
Seizure
Seizure Disorder page 21By: Erika Faye E. Docog
SeizureA 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.
Seizure Disorder page 22By: Erika Faye E. Docog
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
Seizure Disorder page 23By: Erika Faye E. Docog
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
Seizure Disorder page 24By: Erika Faye E. Docog
Seizure Disorder page 25By: Erika Faye E. Docog
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 time recurring seizures occur
The attack is usually related to failure to take prescribed anticonvulsants
Seizure Disorder page 26By: Erika Faye E. Docog
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 Strokes
o Brain tumors
o Severe head trauma
Seizure Disorder page 27By: Erika Faye E. Docog
PATHOPHYSIOLOGY
Status Epilepticus
The exact pathophysiology of why seizure
evolves into status
is complex and not fully understood
Seizure Disorder page 28By: Erika Faye E. Docog
DIAGNOSTIC FINDINGS
Status Epilepticus
EEG – to monitor response to treatment
BLOOD TEST – glucose, electrolytes, liver functions and illicit substances
Seizure Disorder page 29By: Erika Faye E. Docog
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
Seizure Disorder page 30By: Erika Faye E. Docog
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
Seizure Disorder page 31By: Erika Faye E. Docog
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
Seizure Disorder page 32By: Erika Faye E. Docog
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.
Seizure Disorder page 33By: Erika Faye E. Docog
Seizure Disorder page 34By: Erika Faye E. Docog
DEFINITION
Epilepsy
Group of syndromes characterized by recurring seizuresEpileptic syndromes are classified by specific patterns of clinical features, including age of onset, family history and seizure typeCan 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 problemsfever, metabolic and nutritional disorderdrug or alcohol intoxication
also associated with brain tumors, abscess, and congenital malformations
Seizure Disorder page 35By: Erika Faye E. Docog
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
Seizure Disorder page 36By: Erika Faye E. Docog
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
Seizure Disorder page 37By: Erika Faye E. Docog
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)
Seizure Disorder page 38By: Erika Faye E. Docog
Epilepsy
Seizure Disorder page 39By: Erika Faye E. Docog
Epilepsy
Seizure Disorder page 40By: Erika Faye E. Docog
Epilepsy
Seizure Disorder page 41By: Erika Faye E. Docog
Epilepsy
Seizure Disorder page 42By: Erika Faye E. Docog
Epilepsy
Seizure Disorder page 43By: Erika Faye E. Docog
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 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.
Seizure Disorder page 44By: Erika Faye E. Docog
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.
Seizure Disorder page 45By: Erika Faye E. Docog
MEDICAL MANAGEMENT
Epilepsy
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
Seizure Disorder page 46By: Erika Faye E. Docog
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
Seizure Disorder page 47By: Erika Faye E. Docog
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 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
Seizure Disorder page 48By: Erika Faye E. Docog
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
Seizure Disorder page 49By: Erika Faye E. Docog
NURSING MANAGEMENT (cont’d)
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 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
Seizure Disorder page 50By: Erika Faye E. Docog
Seizure Disorder page 51By: Erika Faye E. Docog
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
Seizure Disorder page 52By: Erika Faye E. Docog
COMMON LOCATIONS OF HEADACHE PAIN
Headache
Seizure Disorder page 53By: Erika Faye E. Docog
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
Seizure Disorder page 54By: Erika Faye E. Docog
HeadacheTYPES OF HEADACHE
Seizure Disorder page 55By: Erika Faye E. Docog
HeadacheTYPES OF HEADACHE
Seizure Disorder page 56By: Erika Faye E. Docog
HeadacheTYPES OF HEADACHE
Seizure Disorder page 57By: Erika Faye E. Docog
HeadacheTYPES OF HEADACHE
Seizure Disorder page 58By: Erika Faye E. Docog
HeadacheTYPES OF HEADACHE
Composite drawing of two common methods of ICP monitoring
(A) Iintra-ventricular catheter
(B) Subarachnoid bolt
Seizure Disorder page 59By: Erika Faye E. Docog
HeadacheTYPES OF HEADACHE
Seizure Disorder page 60By: Erika Faye E. Docog
HeadacheTYPES OF SURGICAL PROCEDURES
Seizure Disorder page 61By: Erika Faye E. Docog
Headache
Seizure Disorder page 62By: Erika Faye E. Docog
HeadacheTYPES OF HEADACHE
1. Primary Headache
no organic cause can be identified
include migraine, tension type (muscle contraction), and cluster headaches
Seizure Disorder page 63By: Erika Faye E. Docog
Headache
A. MIGRAINEHEADACHE
Strongly hereditaryMore common in womenTend to occur with stress or life crisisLasts for hour or daysOne side of the head is more affected than the other
TYPES OF HEADACHE1. Primary headache
Seizure Disorder page 64By: Erika Faye E. Docog
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 HEADACHE1. Primary headache
Seizure Disorder page 65By: Erika Faye E. Docog
Headache
A. MIGRAINE HEADACHE
KINDS OF MIGRAINE (cont’d)
TYPES OF HEADACHE1. 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
Seizure Disorder page 66By: Erika Faye E. Docog
HeadacheCAUSE AND SYMTOMS
CAUSE
SYMTOMS
dilatation of blood vessels
a. nausea and vomitingb. chills
c. fatigued. irritabilitye. sweating
f. edema
Seizure Disorder page 67By: Erika Faye E. Docog
HeadacheCAUSE AND SYMTOMS
Seizure Disorder page 68By: Erika Faye E. Docog
HeadacheFOUR 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
Seizure Disorder page 69By: Erika Faye E. Docog
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
FOUR PHASES OF MIGRAINE WITH AURA
Seizure Disorder page 70By: Erika Faye E. Docog
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
FOUR PHASES OF MIGRAINE WITH AURA
Seizure Disorder page 71By: Erika Faye E. Docog
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
FOUR PHASES OF MIGRAINE WITH AURA
Seizure Disorder page 72By: Erika Faye E. Docog
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
FOUR PHASES OF MIGRAINE WITH AURA
Seizure Disorder page 73By: Erika Faye E. Docog
HeadacheDIAGNOSTIC 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
Seizure Disorder page 74By: Erika Faye E. Docog
HeadacheTREATMENT
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
Seizure Disorder page 75By: Erika Faye E. Docog
HeadacheTREATMENT (cont’d)
chocolate,
nuts,
onions,
cow’s milk,
wheat,
egg,
orange,
benzoic acid,
cheese,
tomato
AVOID FOODS LIKE:
Seizure Disorder page 76By: Erika Faye E. Docog
Headache
B. TENSION HEADACHE
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 HEADACHE1. Primary headache (cont’d)
Seizure Disorder page 77By: Erika Faye E. Docog
HeadacheSYMTOMS AND TREATMENT
SYMPTOMS
TREATMENT
sustained contraction of head and neck muscles
Non narcotic analgesics
Relaxation technique
Amitriptyline
Seizure Disorder page 78By: Erika Faye E. Docog
Headache
C. CLUSTER 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 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 HEADACHE1. Primary headache (cont’d)
Seizure Disorder page 79By: Erika Faye E. Docog
HeadacheSYMTOMS AND TREATMENT
SYMPTOMS
TREATMENT
Flushing
Tearing of eyes
Nasal stuffiness
Sweating
Swelling of temporal vessels
Narcotic analgesic I.M. during acute phase100% oxygen by face mask for 15 minutesergotamine tartratesumatripanSteroidsPercutaneous sphenopalatine ganglion blockade
Seizure Disorder page 80By: Erika Faye E. Docog
Headache
D. CRANIAL ARTERITIS
Cause of headache in older population, reaching its greatest incidence in
those older than 70 years old
TYPES OF HEADACHE1. Primary headache (cont’d)
Seizure Disorder page 81By: Erika Faye E. Docog
HeadacheSYMTOMS AND TREATMENT
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
Seizure Disorder page 82By: Erika Faye E. Docog
HeadacheTYPES 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
Seizure Disorder page 83By: Erika Faye E. Docog
HeadacheASSESSMENT
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)
Seizure Disorder page 84By: Erika Faye E. Docog
HeadacheDIAGNOSTIC 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 CBCerythrocyte sedimentation rateelectrolytesglucosecreatininethyroid hormone level
Seizure Disorder page 85By: Erika Faye E. Docog
HeadacheFACTORS PRECIPITATING HEADACHE
Emotional problems
Stress
Sleep patterns
Recreational interest
Appetite
Family stressors
Seizure Disorder page 86By: Erika Faye E. Docog
HeadacheNURSING MANAGEMENT
To enhance pain relief
To treat the acute event of the headache
To prevent recurrent episodes
Seizure Disorder page 87By: Erika Faye E. Docog
HeadacheNURSING MANAGEMENT (cont’d)
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
Seizure Disorder page 88By: Erika Faye E. Docog
HeadacheNURSING MANAGEMENT (cont’d)
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
Seizure Disorder page 89By: Erika Faye E. Docog
Seizure Disorder page 90By: Erika Faye E. Docog
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
Seizure Disorder page 91By: Erika Faye E. Docog
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
Altered Level of Consciousness
Seizure Disorder page 92By: Erika Faye E. Docog
oIs a state of unresponsiveness to the environment in which the
patient makes no movement or sound but sometimes opens the
eyes
Altered Level of Consciousness
AKINETIC MUTISM
Seizure Disorder page 93By: Erika Faye E. Docog
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
Altered Level of Consciousness
Seizure Disorder page 94By: Erika Faye E. Docog
PATHOPHYSIOLOGY
oAltered LOC is not a disorder itself; rather, it is a result of multiple
pathophysiologic phenomena.
Altered Level of Consciousness
Seizure Disorder page 95By: Erika Faye E. Docog
CAUSES
Altered Level of Consciousness
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.
Seizure Disorder page 96By: Erika Faye E. Docog
CLINICAL MANIFESTATIONS
Altered Level of Consciousness
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, 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.
Seizure Disorder page 97By: Erika Faye E. Docog
ASSESSMENTS
Altered Level of Consciousness
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.
Seizure Disorder page 98By: Erika Faye E. Docog
DIAGNOSTIC FINDINGS
Altered Level of Consciousness
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,
Seizure Disorder page 99By: Erika Faye E. Docog
COMPLICATIONS
Altered Level of Consciousness
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.
Seizure Disorder page 100By: Erika Faye E. Docog
MEDICAL MANAGEMENT
Altered Level of Consciousness
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
Seizure Disorder page 101By: Erika Faye E. Docog
NURSING MANAGEMENT
Altered Level of Consciousness
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
Maintaining
the
airway
Seizure Disorder page 102By: Erika Faye E. Docog
NURSING MANAGEMENT (cont’d)
Altered Level of Consciousness
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
Supporting
the
Family
Seizure Disorder page 103By: Erika Faye E. Docog
NURSING MANAGEMENT (cont’d)
Altered Level of Consciousness
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
Promoting
Sensory
Stimulation
Seizure Disorder page 104By: Erika Faye E. Docog
NURSING MANAGEMENT (cont’d)
Altered Level of Consciousness
Begin to teach activities of daily as soon as consciousness returns
Support, encourage, and supervise patient’s effort
Attaining
Self
Care
Seizure Disorder page 105By: Erika Faye E. Docog
Seizure Disorder page 106By: Erika Faye E. Docog
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
Seizure Disorder page 107By: Erika Faye E. Docog
CLINIICAL MANIFESTATION
Increased Intracranial Pressure
When ICP increases to the point where the brain’s ability to adjust
has reached its limits, neural function is impaired. Increased ICP is
manifested by changes in level of consciousness and abnormal
respiratory and vasomotor responses.
Seizure Disorder page 108By: Erika Faye E. Docog
CLINIICAL MANIFESTATION (cont’d)
Increased Intracranial Pressure
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.
Seizure Disorder page 109By: Erika Faye E. Docog
ASSESSMENT AND DIAGNOSTIC METHODS
Increased Intracranial Pressure
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).
Seizure Disorder page 110By: Erika Faye E. Docog
MEDICAL MANAGEMENT
Increased Intracranial Pressure
Increased ICP is a true emergency and must be treated
promptly. Immediate management involves decreasing cerebral
edema, lowering the volume of CSF, and decreasing blood volume
while maintaining cerebral perfusion.
Seizure Disorder page 111By: Erika Faye E. Docog
PHARMACOLOGIC THERAPY
Increased Intracranial Pressure
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
Seizure Disorder page 112By: Erika Faye E. Docog
NURSING MANAGEMENT
Increased Intracranial PressureTHE
UNCONSCIOUS PATIENT
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 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.
Seizure Disorder page 113By: Erika Faye E. Docog
NURSING MANAGEMENT
Increased Intracranial Pressure
NURSING ALERT!
Changes in vital signs may be a late
sign of increased ICP. As ICP increases, pulse
rate and respiratory rate decreased, and blood
pressure and temperature rise.
Observe for widening pulse pressure,
bradycardia, and respiratory irregularity: Cheyne-
Storked breathing and ataxic breathing (Cushing’s
triad). Widened pulse pressure is a serious
development. Immediate surgical intervention is
indicated if the major circulation begins to
decrease as a result of brain compression.
Seizure Disorder page 114By: Erika Faye E. Docog
DIAGNOSIS
Increased Intracranial Pressure
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
Seizure Disorder page 115By: Erika Faye E. Docog
DIAGNOSIS (cont’d)
Increased Intracranial Pressure
Brain stem herniation
Diabetes insipidus
Syndrome of inappropriate antidiuretic hormone (SIADH) secretion
COLLABORATIVE PROBLEMS / POTENTIAL COMPLICATIONS
Seizure Disorder page 116By: Erika Faye E. Docog
PLANNING OF GOALS
Increased Intracranial Pressure
The major goals of the patient may include adequate
cerebral tissue perfusion through reduction of ICP, normal respiration,
patent airways, restored fluid balance, normal urine and bowel
elimination, absence of infection, and absence of complications.
Seizure Disorder page 117By: Erika Faye E. Docog
NURSING INTERVENTION
Increased Intracranial Pressure
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
Seizure Disorder page 118By: Erika Faye E. Docog
NURSING INTERVENTION (cont’d)
Increased Intracranial Pressure
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
Seizure Disorder page 119By: Erika Faye E. Docog
NURSING INTERVENTION (cont’d)
Increased Intracranial Pressure
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-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
Seizure Disorder page 120By: Erika Faye E. Docog
NURSING INTERVENTION (cont’d)
Increased Intracranial Pressure
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)
Seizure Disorder page 121By: Erika Faye E. Docog
NURSING INTERVENTION (cont’d)
Increased Intracranial Pressure
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
Seizure Disorder page 122By: Erika Faye E. Docog
NURSING INTERVENTION (cont’d)
Increased Intracranial Pressure
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 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
Seizure Disorder page 123By: Erika Faye E. Docog
NURSING INTERVENTION (cont’d)
Increased Intracranial Pressure
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
Seizure Disorder page 124By: Erika Faye E. Docog
EVALUATION
Increased Intracranial Pressure
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
Seizure Disorder page 125By: Erika Faye E. Docog
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