Neurovascular Disorders

Neurovascular Disorders
CVA, TIA, Cerebrovascular defects, Head Injuries, Brain Tumors, Increased Intracranial Pressure, Epilepsy and Seizures

Objectives Discuss various neurological disturbances in motor function and sensory/perceptual function Discuss the etiology/pathophysiology, clinical manifestations, assessment, diagnostic tests, medical management, and nursing interventions for a stroke patient

Objectives List 5 signs of increased intracranial pressure and why they occur List nursing interventions that decrease intracranial pressure List 4 classifications of seizures, their characteristics, clinical signs, aura, and postictal period

Objectives Discuss the etiology/pathophysiology, clinical manifestations, assessment, diagnostic tests, medical management, and nursing interventions for intracranial tumors, craniocerebral trauma, and spinal cord trauma

Objectives Discuss patient teaching and home care planning for a patient with a neurological disorder

Cerebrovascular Accidents
6

Stroke An abrupt impairment of brain function resulting in a set of neurologic signs and symptoms that are caused by impaired blood flow to the brain and last more than 24 hours 7

Risk Factors for Stroke
Nonmodifiable factors Risk factors that cannot be changed Age, race, gender, and heredity Modifiable factors Those that can be eliminated or controlled Contributing causes: atherosclerosis, HTN, DM, obesity, smoking, high cholesterol, stress, cocaine use, sedentary lifestyle, oral contraceptives. 8

Vascular Problems Stroke (cerebrovascular accident=CVA)
Also known as “brain attack” Etiology/pathophysiology Abnormal condition of the blood vessels of the brain, characterized by hemorrhage into the brain, or Formation of an embolus or thrombus that occludes an artery  ischemia to brain tissue affected by the occlusion Cerebrovascular accident (CVA), or stroke, is a sudden loss of brain function accompanied by neurological deficit. It is the Third highest cause of death in U.S. Strokes can be caused by ischemia (oxygen deprivation) resulting from: a Thrombus, an Embolus, Severe vasospasm, or Cerebral hemorrhage. Neurological deficits can be temporary or permanent and may include: loss of Sensation, loss of Movement, deficits in Thought processes, Memory deficits, and loss of or altered Speech. Transient ischemic attacks (TIAs) frequently precede a CVA; and are transient, temporary dysfunction. They Can last seconds, minutes, or up to 24 hours. The Classic symptom is fleeting blindness in one eye. TIA or CVA symptoms vary with the location of interrupted blood supply in the brain. Common neurological deficits are motor: Hemiplegia, Hemiparesis, Dysarthria, Dysphagia, and Loss of emotional control and behaviors also common. Sensory deficits include: Double vision, Decreased visual acuity, Homonymous hemianopia, Decreased sensation to: Touch, Pressure, Pain, Heat, and Cold. Intellectual deficits include: Memory impairment, Poor judgment, Short attention span, Difficulty organizing thoughts, and Inability to reason or calculate. Emotional deficits include: Depression, Decreased tolerance to stressors, and Initial bowel and bladder dysfunction. CVA clients have varying symptoms dependent upon which side of the brain is affected.

Figure 14-16 Three types of stroke.
(From Lewis, S.M., Heitkemper, M.M., Dirksen, S.R. [2004]. Medical-surgical nursing: assessment and management of clinical problems. [6th ed.]. St. Louis: Mosby.) Three types of stroke.

Vascular Problems Stroke cont.
Causes neurological deficits of sensation, movement, thought, memory, or speech. Strokes may leave people with serious, long-term disability such as: Hemiparesis Inability to walk Complete or partial dependence in ADLs Aphasia or dysphagia

Vascular Problems Clinical manifestations/assessment
Can affect body functions, personality, spatial-perceptual alterations, sensation and communication The functions affected are directly related to the artery involved and the area of brain that it supplies. Permanent damage can result due to anoxia of the brain

Strokes Classified as : ischemic or hemorrhagic
Ischemic strokes are further classified as: Thrombotic or embolic

Stroke: Pathophysiology
Hemorrhagic stroke Blood vessel in brain ruptures; bleeding into the brain occurs Ischemic stroke Obstruction of blood vessel by atherosclerotic plaque, blood clot, or a combination of the two, or by other debris released into vessel that impedes blood flow to an area of the brain 14

Figure 28-4 15

Stroke Thrombotic Stroke
Thrombosis is the most common cause of stroke HTN and DM accelerate the atherosclerotic process Seen most often in the year old age group If vessel becomes occluded  ischemia  infarction occurs Usually occur in the larger vessels

Stroke Thrombotic stroke cont.
Symptoms: tend to occur during sleep or shortly after rising Neurological s/sx worsen for 72 hrs as edema increases in the infarcted area of the brain

Stroke Embolic Stroke The emboli most commonly originates from a thrombus in the endocardial (inside) layer of the heart Caused by rheumatic heart disease, mitral stenosis, AF, MI, atrial-septal defects Emboli travels upward to the cerebral circulation and lodges where a vessel narrows. Most frequently occur in the midcerebral artery

Stroke Hemorrhagic Stroke
Bleeding into the brain or subarachnoid space  destroys or replaces brain tissue Often caused by aneurysms which are a localized dilation of the wall of a blood vessel

Stroke Hemorrhagic Stroke cont.
Aneurysm: usually caused by atherosclerosis, HTN, trauma, or infection, or congenital weakness in a blood vessel wall It ruptures as a result of a small hole  hemorrhage spreads rapidly. Hemorrhage begins to absorb within 3 weeks Recurrent rupture is a risk for 7-10 days after the initial hemorrhage

Transient Ischemic Attack
Temporary neurologic deficit caused by impairment of cerebral blood flow Usually lasts less than 24 hrs.; most resolve within 3 hrs. Blood vessels occluded by spasms, fragments of plaque, or blood clots Important warning signs for the individual experiencing a full stroke 21

Signs and symptoms Dizziness, momentary confusion, loss of speech, loss of balance, tinnitus, visual disturbances, ptosis, dysarthria, dysphagia, drooping mouth, weakness, and tingling or numbness on one side of the body; ataxia Between attacks, neurological status is normal 22

Medical diagnosis Health history, physical examination findings, and results of brain imaging studies CT without contrast media is the most important diagnostic study Laboratory studies, electrocardiography (ECG), duplex ultrasonography, and cerebral angiography may also be used

Medical treatment Depends on the location of the narrowed vessel and the degree of narrowing Acetylsalicylic acid (aspirin), ticlopidine hydrochloride (Ticlid), extended-release dipyridamole (Aggrenox), or clopidogrel bisulfate (Plavix) decrease platelet clumping Warfarin (Coumadin) and heparin - anticoagulants 24

Surgical Treatment may include: Carotid endarterectomy and transluminal angioplasty Carotid endarterectomy: removal of atheromatous lesion to enable increased blood flow Transluminal angioplasty – the insertion of a balloon to open a stenosed artery to allow increased blood flow

Figure 28-3 26

Strokes Assessment: Subjective Data: description of onset of symptoms; presence of headache; sensory deficits: numbness, tingling, inability to think clearly, visual problems Objective Data: presence of hemiparesis or hemiplegia; LOC, s/sx ICP, respiratory status, aphasia or dysphagia

Stroke Diagnostic Tests
CT: can indicate size, location of the lesion and differentiate between ischemic and hemorrhagic stroke MRI – can determine extent of brain injury PET scan – useful in assessing the extent of tissue damage by showing the

Stroke Medical management
If the patient has had a hemorrhagic stroke as a result of an aneurysm – surgery may be needed Tie off or clip the aneursym; remove the clot Treat [within 96 hrs. of bleeding] with calcium channel blockers x21 days Medical Management includes: Airway maintenance and supportive therapy during first 24 to 48 hours. Early diagnosis of cause and type of stroke is important to recovery. One of the goals of treatment is to Maintain adequate cerebral perfusion, and Prevent cerebral edema. Respiratory failure is treated with mechanical ventilation. Temperature may need to be regulated with a hypothermia blanket. The Focus is on rehabilitation from admission. Surgical treatment may include: Surgical removal of thrombus or embolus may be necessary to relieve pressure on the brain. Pharmacological therapies may include: Antihypertensive agents. To prevent further clot formation in thrombi cases: Anticoagulants, Aspirin, Heparin, or Coumadin may be used. To dissolve clots:Alteplase (Activase), Anistreplase (Eminase), Streptokinase (Streptase), Urokinase (Abokinase), and Thrombolytic agents. Dexamethasone (Decadron) may be used to reduce cranial pressure Anticonvulsants such as phenytoin (Dilantin), may also be used. Dietary considerations include: Fluids are restricted for a few days following a CVA, Intravenous fluids or tube feedings, The gag reflex must be assessed to identify choking risk. Activity considerations include: For embolic or thrombolic stroke, bed kept flat to increase cerebral perfusion. For hemorrhagic stroke, head of bed elevated to decrease cerebral perfusion. Collaborative Care is necessary and includes Physical, occupational, and speech therapy which are vital for optimal functional recovery. Nursing Management includes: Maintain patent airway and fluid & electrolyte balance, Ensure adequate nutrition, Provide mouth and eye care, Keep client’s body in correct alignment, use footboard to prevent foot drop and contractures, Prevent pneumonia by turning client at least every 2 hours, Perform and assist client to perform ROM exercises using unaffected side to exercise the affected side, Communicate with the client, Set realistic short-term goals, and Involve client’s family in client care when possible.

Aneurysm Clipping

Stroke Medical Management Ischemic Stroke Thrombolytics
T-PA (clot buster!) [Tissue Plasminogen Activator] Digests fibrin and fibrinogen lysing the clot; must be administered within 3 hrs of onset of symptoms Pts. Screened carefully for  coagulation disorders, recent GI bleed, r/o hemorrhagic stroke May not be candidate for thrombolytic treatment Patient choice factor

Stroke Medical Management cont. Ischemic Stroke cont.
Heparin and Coumadin – to prevent formation of more clots. Used after the first 24 hrs. if treated with t-PA Drugs to reduce intracranial pressure: Decadron (steroid) Bowel meds (to reduce straining)

Stroke Medical Management cont. Fluids restricted first few days
First 24-48hrs: Airway maintenance and supportive treatment Antihypertensives Fluids restricted first few days IV or Feeding tube may be utilized

Strokes Medical Management cont. Other:
P.O. food/fluids: pureed, soft, regular Neurological checks Bedrest – depends on the type of stroke, deficits, and the judgment of the MD Physical, occupational, and/or speech therapy

Stroke: Signs and Symptoms
Different signs and symptoms, depending on the type, location, and extent of brain injury Hemorrhagic stroke Occurs suddenly; may include severe headache described as “the worst headache of my life” Other symptoms: stiff neck, loss of consciousness, vomiting, and seizures 35

Embolic stroke Appear without warning One or more of the following signs and symptoms: one-sided weakness, numbness, visual problems, confusion and memory lapses, headache, dysphagia, and language problems 36

Aphasia A defect in the use of language; speech, reading, writing, or word comprehension Dysarthria The inability to speak clearly Dysphagia Swallowing difficulty Dyspraxia The partial inability to initiate coordinated voluntary motor acts Hemiplegia Defined as paralysis of one side of the body 37

Sensory impairment Unable to feel touch, pain, or temperature in affected body parts Unilateral neglect Do not recognize one side of the body as belonging to them Homonymous hemianopsia Perceptual problem: involves loss of one side of field of vision Elimination disturbances Neurogenic bladder Flaccid bladder Bowel incontinence 38

Figure 28-5 39

Figure 28-8 40

Prognosis Prognosis for TIA or stroke increasingly hopeful
Critical variables for recovery: patient’s condition before the stroke, time between stroke and diagnosis, treatment and support in acute phase (usually the first 48 hours), severity of patient’s symptoms, and access to rehabilitative therapy Long-term recovery may depend on the care received immediately after the stroke Most recovery takes place in the first 3-6 months, but progress often continues long after that 41

Stroke Nursing Intervention
Goals during the initial phase are aimed at preventing neurological deficits Neurological Assessments at regular intervals Nutrition: route and texture depend on swallow ability Self-care deficit and assistance needed. Start teaching process

Stroke Nursing Interventions cont.
Elimination: insert/remove urinary catheter; monitor s/sx of UTI; bladder and bowel training Mobility ROM/exercise/activity: issue: unilateral neglect Emotional lability/ depression

Stroke Nursing Interventions cont.
Communication: many stroke patients have speech problems ST will evaluate and treat Approach in an unhurried way Communication board may be helpful Inability to articulate doesn’t mean cognitive impairment

Stroke Patient Teaching Techniques to compensate for the deficit(s)
“Rehabilitation” starts with admission to the acute facility Medication instruction “Stroke Club” referral for support Safety Communication Caregiver stress relief

Nursing Care in the Rehabilitation Phase
Interventions Self-Care Deficit Risk for Injury Ineffective Coping Impaired Verbal Communication Imbalanced Nutrition Impaired Physical Mobility Constipation Total and Functional Urinary Incontinence 46

Figure 28-6 47

Figure 28-7 48

Figure 28-9 49

Discharge Patients may be discharged to home or go to specialized rehabilitation centers for continued therapy Outpatient therapy is an option for some patients When able, patients are transitioned back into the home setting Essential to include family, friends, and significant others in this process 50

Discharge During and after the rehabilitation phase, patients and families need to be made aware of resources to help them deal with continuing disabilities In rehabilitation, the patient is respectfully challenged to return to the highest level of function possible 51

Craniocerebral Trauma
Head Injury

Injuries to the brain can result from direct or indirect trauma Indirect trauma is caused by tension strains and shearing forces transmitted to the head by stretching the neck Direct Trauma occurs when the head is directly injured acceleration-deceleration injury with rotation of the skull and its contents  bruising or contusion of the occipital and frontal lobes and the brainstem and cerebellum

Clinical Manifestations “open” or “closed” injury Open head injuries result from skull fractures or penetrating wounds Amount of injury is determined by the velocity, mass, shape, and direction of impact Skull fracture may also occur Fractures at the base of the skull are more serious because of their location near the medulla

Skull cont. Injuries and fractures may occur with or without brain injury. Closed fracture: dura mater intact Open fracture: dura mater torn Closed Head Injury: Includes concussions, contusions, lacerations Hemorrhaging may occur in the: scalp, epidural, subdural, intracerebral, and intraventricular places

Clinical Manifestations cont. Closed Head Injuries cont. Scalp injuries Lacerations, contusions, abrasions, and hematomas Concussion Trauma with no visible injury to the skull or brain Temporary loss of consciousness

Craniocerbral Trauma Closed Head Injury cont. Contusion
Bruising and bleeding in the brain tissue Hematoma Subdural or epidural hematoma Intracerebral or Subarachnoid hemorrhage From lesions within the tissue of the brain itself SCALP BLEED bleed profusely. Infection major concern, wound cleansed and irrigated, close with sutures or butterfly dressings 57

Coup Contra Coup Coup injury caused by impact of head against object
Contrecoup caused by impact of brain against opposite side of skull Types of closed head injuries: Concussion (shaking of brain_) contusion ( surface bruises of brain) Laceration (tearing of cortical tissue)

Hematomas Epidural Subdural
Arterial bleed that forms rapidly between dura and skull EMERGENCY! Note: if lethargy or unconsciousness develop after the patient regains consciousness, an epidural hematoma may be suspected and needs immediate treatment! Subdural Forms as venous blood collects below the dura Forms more slowly than epidural bleed Symptoms vary depend upon type of bleeding Nucal rigidity is stiffness or inability to bend neck Hemiplegic is paralysis of one side of body Paraplegia is paralysis of lower extremities of body

Hematomas Subdural cont.
The clot will cause pressure on the brain surface and will displace brain tissue Note: if a patient who has been conscious for several days after head injury loses consciousness or develops neurological signs and symptoms, a subdural hematoma should be suspected

Assessment Subjective Data: pt. understanding of the injury and resulting trauma; able to define how the trauma happened; c/o nausea, vomiting, loss of consciousness, abnormal sensations, bleeding from any orifice Objective Data: respiratory status, LOC, Pupil size and responsiveness check freq., VS, presence of bleeding; vomiting, abnormal speech. Presence of “battle’s sign” – small hemorrhagic spot behind the ear (poss. fracture of lower skull).

Diagnostic Tests: CT, MRI, PET scan to assess soft tissue injuries Medical Management Immediate care is life-saving measures and maintenance of normal body functions until recovery is ensured Maintain patent airway, adequate oxygenation If suctioning needed, do not use nasal passages due to possibility of skull fx.

Medical Management cont. Medications to reduce cerebral edema and increased intracranial pressure Analgesics that do not depress respirations Anticonvulsants prn seizure prevention Measures to provide cooling if elevated temp Surgery

Surgical treatment Directed at evacuating hematomas and débriding damaged tissue Bone flap removed to relieve pressure Catheter may be inserted into the ventricles to remove CSF and monitor intracranial pressure Burr holes used to treat epidural and subdural hematomas 64

Surgery

Increased Intracranial Pressure (ICP)
Can occur suddenly, progress rapidly, and often requires surgical intervention Can be fatal if not stopped and reversed

Increased Intracranial Pressure
Etiology/pathophysiology An increase in any content of the cranium Blood, CSF, tissue, infection, edema Cranial vault is rigid and non-expandable Build up of pressure can occur slowly or rapidly involving one or both sides of the brain Rising of pressure decreased cerebral blood flow  inadequate perfusion of the brain Changes in PCO2, PO2, and pH  vasodilation and cerebral edema  further increased pressure  brainstem herniation The etiology/pathophysiology for increased intracranial pressure includes: anIncrease in any content of the cranium, or Space-occupying lesions, cerebrospinal problems, or cerebral edema. Causes of increased intracranial pressure include:Increased blood volume from vascular vasodilatation, Increased volume of brain tissue from edema, Infection, Tumor, Hemorrhage, Increased CSF from overproduction, Decreased reabsorption or interruption of CSF circulation If pressure continues to increase, brain herniation occurs, resulting in death Regulatory mechanisms maintain intracranial pressure between 0 and 15 mm Hg. When mechanisms fail, neurological changes occur: Which include: Deteriorating level of consciousness, Decreased motor response, Fixed, dilated pupils, Vital sign changes (known as Cushing’s triad or reflex).

Clinical manifestations/assessment Change in level of consciousness (EARLY SIGN!) Diplopia Headache Abnormal vital signs (irregular resp., increase BP, decrease HR, elevated temp.) Pupillary signs Vomiting Changes in motor function (weakness, hemiplegia, positive Babinski’s reflex, decorticate or decerebrate posturing, and seizures)

Assessment: early detection  meaures to reverse condition Subjective Data: pt. understanding of their condition, c/o visual changes, nausea, pain, personality change, change in ability to think Double vision (diplopia) occurs early in the process of ICP Headache – usually increases with coughing, straining at stool, or stooping.

Objective Data: Chart what is seen; not what is inferred Change in LOC Pupils check – pupils will usually change on the same side as the lesion First and most subtle clue: sluggish pupillary response *Dilated pupils that respond slowly to light are a sign of impending brainstem herniation A pupil that is fixed and dilated is called “blown”

Cushing’s Triad Late sign of increased ICP (brain herniation) Other:
Increased systolic BP Widened pulse pressure Bradycardia Other: +/- irregular respirations Elevated temperature

Characteristic posturing when upper brainstem is herniated: Decorticate response: flexion of arms, wrists, and fingers with adduction in upper extremities; in lower extremities – extension, internal rotation, and plantar flexion Decerebrate response: all 4 extremities in rigid extension, hyperpronation of forearms and plantar extension of feet *P. 669, Figure 14-8

Diagnostic Tests: CT, MRI Because acute increased intracranial pressure is a medical emergency, there is little time for diagnostic tests [LP is contraindicated] Frequent and careful observations and neurological testing The presence of even subtle changes can be very significant. Internal measuring devices in postop or critically ill patients

Medical Management Goal: identify and treat the underlying cause of ICP Mechanical decompression Craniotomy Craniectomy Drain ventricles or subdural hematoma Medications: osmotic diuretics (e.g. Mannitol), corticosteroids(eg. Decadron), and anticonvulsants (eg. Dilantin) Medical-Surgical Management is Focused on early recognition and treatment of intracranial pressure and maintenance of normal body functions. Medical management includes: Suctioning may be necessary, Oxygen given to maintain cerebral perfusion, Arterial blood gases (ABGs) checked If endotracheal tube in place, PaCO2 level can drop below normal:Causes slightly alkaline pH which decreases vasodilation, and thus, intracranial pressure Surgical management includes: Surgical decompression removes bone flap from skull to allow room for brain expansion. Lesions, tumors, hematomas, or abscesses may be surgically removed. Excess CSF may be drained from the ventricles. Pharmacological management includes: Corticosteroids such as dexamethasone (Decadron) given to reduce edema, Antacids such as Mylanta or Maalox, Histamine receptor antagonists such as cimetidine (Tagamet), Osmotic diuretics such as mannitol (Osmitrol), Muscle relaxants, Sedatives, Barbiturates, Muscle paralyzing agents, Antipyretics, and Anticonvulsants. Activity is Limited to keep metabolic needs of brain minimal. Nursing Management includes: Frequently monitoring level of consciousness, eye movements, pupil changes, vital signs, I&O, and pulse oximetry. Maintaining airway patency and administering oxygen as ordered. Keep the head of bed at 30 to 40 degrees and client’s head positioned at midline. Watch for signs of arm/leg muscle weakness, muscle twitching, nausea or vomiting, and visual or hearing disturbance. Fluids will often be restricted.

Nursing Interventions Therapeutic Measures (to reduce venous volume): Elevating HOB degrees Neck in neutral position Position pt. to avoid flexion of the hips, waist, and neck (reduces intrabdominal and intrathoracic pressure that can  increase ICP) Instruct pt. to avoid isometric or resistive exercises

Nursing Interventions/ Therapeutic Measures cont. Restrict fluid intake Measures to help pt. avoid Valsalva’s maneuver (forced expiratory effort against a closed airway –e.g. straining to have a BM) Foley cath prn Suction only prn Administer O2 Hyperthermia blanket prn

Intracranial Tumors

Intracranial Tumors Etiology/pathophysiology
Benign (meningioma) or malignant (glioma) Primary or metastatic May affect any area of the brain; named for the area from which they arise Drug/environmental factors may play a role in development Space occupying intracranial lesions, may be either benign or malignant. May be primary or metastatic lesions.

Intracranial Tumors Assessment
Subjective Data: pt. understanding of diagnosis; changes in personality or judgment; c/o abnormal sensations, visual problems, unusual odors; c/o headache, hearing loss, or inability to carry out ADLs Objective Data: motor strengths, gait, LOC, pupil status, speech abnormalities, cranial nerve abnormalities, s/sx of ICP, presence of seizures Clinical manifestations differ according to area of lesion and growth rate; but commonly include: Alterations in consciousness, Decreased mental functioning, Headaches, Seizures, and Vomiting (sometimes sudden and projectile). Other symptoms are relative to the function of the area involved.

Intracranial Tumors Diagnostic Tests: CT, MRI, PET, EEG
Medical Management Surgical removal of tumor Craniotomy Intracranial endoscopy Radiation Chemotherapy Combination of above Medical management is Based on tissue-type, growth rate, and the client. Radiation therapy may be administered for: Treatment of specific tumor types such as Inoperable tumors and may Also used in conjunction with surgery and chemo. Surgical treatement may include: Conventional or laser surgery for resection of tumors to: Decrease the space occupied by the lesion, And Obtain tissue for biopsy. Some CSF may be removed to relieve increased pressure. Pharmacological therapies are Based on presenting symptoms and may include: Dexamethasone (Decadron) to decrease cerebral edema, Phenytoin (Dilantin) to prevent seizure, Antacids and H2 blockers such as cimetidine (Tagamet), Analgesics, NSAIDs, Codeine, Stool softeners, and Antineoplastic agents. Nursing Management may include: Prepare client and family for surgery in a caring, compassionate manner, and Explaining procedures, including shaving the head. The Client is generally in ICU for several days.

Intracranial Tumors Nursing Interventions Preoperative preparation
Baseline neurological assessment *Most Important with any patient Postoperative care is determined by the pt. condition Assess for s/sx ICP

Intracranial Tumors Nursing Diagnoses (r/t, AEB: Nanda Approved)
Acute Pain Disturbed Thought Processes Disturbed Sensory Perception Impaired Physical Mobility and Self-Care Deficit Ineffective Coping Focus a lot on client teaching 83

Epilepsy/Seizure Disorder

EPILEPSY/SEIZURE DISORDER
A transitory disturbance in consciousness or motor, sensory, or autonomic function with or without loss of consciousness Associated with paroxysmal , uncontrolled electrical discharges in the neurons of the brain sudden, violent, involuntary contractions of a group of muscles Causes: hypoglycemia, infection, electrolyte imbalance, drug and alcohol withdrawal, and water intoxication

Clinical Manifestations Classifications: Generalized tonic-clonic (grand mal) Absence (petit mal) Psychomotor (automatisms) Jacksonian (focal) Miscellaneous (myoclonic, akinetic) See Table 14-6 for more specifics (p )

Clinical Manifestations cont. Postictal Period: pt. usually feels groggy and acts disoriented; sometimes c/o headache and muscle aches; often sleeps; may experience amnesia Status epilepticus Medical emergency: continuous seizures or repeated seizures in rapid succession for 30 minutes or more

Assessment: Subjective Data: pt. awareness of the disorder and any precipitating factors; may c/o presence of an “aura” preceding a seizure Aura: a sensation such as light or warmth that may precede a migraine attack or seizure; may be psychic, sensory with olfactory, visual, auditory, or taste hallucinations Objective Data: # seizures occurring in a given time period; character of the seizures, behaviors noted, injuries incurred.

Diagnostic Tests: EEG Medical Management: Medications (see Table 14-7 p. 679) ADL – driving car, operating machinery, swimming should be avoided until seizures are controlled

Nursing Interventions: Care during a seizure Primary goal: protection from aspiration and injury; and observation and recording of the seizure activity DO NOT LEAVE PATIENT ALONE! Support and protect the head If possible, turn head to one side to maintain airway.

Nursing Interventions: Care during a seizure cont. Loosen clothing around neck DO NOT RESTRAIN THE PATIENT DO NOT TRY TO PRY OPEN THE JAW TO INSERT PADDED TONGUE BLADE OR OTHER OBJECT Padded siderails may be used – esp. if seizure activity at night

Nursing Diagnoses may incude: Ineffective airway clearance r/t mucus accumulation in oropharyngeal area during seizure Risk for injury r/t rapid onset of altered state of consciousness and seizure activity

Nursing Diagnosis and Patient Teaching Ineffective Coping and Deficient Knowledge Teach family and patient about the seizure disorder, the therapy, & good follow-up care. Teaching must be directed toward helping the patient and family adjust to a chronic condition Instruct re: use medic alert bracelet/necklace Encourage questions and concerns Explain restrictions

Vagus Nerve Stimulator
A generator, similar to a pacemaker, is implanted under the skin on the patients chest. The electrodes (wires) are then wrapped around the vagus nerve. The generator sends electrical impulses to the vagus nerve, which carries those impulses to the CNS This impulses may stop a seizure or lessen the severity of a seizure

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