Exam 24 - Conductive Abnormalities

• Seizure activity results from abnormal electrical activity in the brain.
• Seizures can be caused by severe elevations in body temperature, drug use, electrolyte imbalance, brain tumors, brain infection, and epilepsy itself.
• Seizures are classified based on the features of the attack, including generalized tonic-clonic (grand mal), absence (petit mal), psychomotor (automatisms), jacksonian (focal), and miscellaneous (myoclonic and akinetic) seizures.
• Epilepsy is associated with paroxysmal, uncontrolled electrical discharges in the neurons, leading to sudden, violent, involuntary muscle contractions.
• Neuronal discharges may cause tonic convulsions with alternating contraction and relaxation of muscle groups, resulting in tonic-clonic jerking movements.
• Seizures are followed by a variable rest period called the postictal period, during which the patient may feel groggy, disoriented, and experience headache, muscle aches, amnesia, or sleep.
• Status epilepticus is recurrent, generalized seizure activity without regaining full consciousness between seizures, needing immediate medical intervention.
• Repeated seizures exhaust the brain's energy supply, potentially causing permanent brain damage or death.
• The most common cause of status epilepticus is sudden withdrawal of anticonvulsant medications.
• Nursing interventions for status epilepticus involve ensuring a patent airway and protecting the patient from injury.
• Medications may be given in high doses to stop seizure activity, potentially rendering the patient unconscious.
• Inserting a Foley catheter, starting an IV line, and intubating for ventilatory support may be needed.
• Status epilepticus (SE) is a life-threatening medical emergency when seizures occur in close proximity.
• Status epilepticus is more likely with tonic-clonic seizures that have a specific causative factor as opposed to idiopathic seizures.
• Frequent factors precipitating SE are irregular antiepileptic drug intake, withdrawal from alcohol or sedatives, electrolyte imbalance, azotemia, head trauma, infection, and brain tumor.
• Physiological changes during SE happen in two phases

Phase 1 of Status Epilepticus

• Increased cerebral metabolism
• Compensatory mechanisms (CBF increase) prevent cerebral damage from hypoxia or metabolic injury.
• Hyperglycemia occurs from epinephrine release
• Activation of hepatic gluconeogenesis.
• Hypertension arises from increased CBF.
• Hyperpyrexia comes from excessive muscle and catecholamine release.
• Lactic acidosis results from anaerobic metabolism.
• Elevated epinephrine and norepinephrine with acidosis contribute to heart dysrhythmias.

Phase 2 of Status Epilepticus

• Develops 30-60 minutes after phase 1
• Decompensation occurs since metabolic demands are unmet
• Induces decreased CBF
• Systemic hypotension
• Increased ICP
• Cerebral autoregulation failure
• Body develops metabolic and respiratory acidosis from hypoxemia and hypoglycemia caused by depleted energy.
• Cellular injury is due to deprivation of Oxygen and Glucose
• Common pulmonary edema
• Aspiration is known to arise from reduced laryngeal reflex sensitivity.
• Hypoxemia, hyperkalemia, increased muscle activity, and metabolic acidosis can cause cardiac dysrhythmias and heart failure.
• Kidney injury can arise from severe rhabdomyolysis and acute myoglobinuria.
• Myoglobin released by excessive muscle activity from prolonged skeletal contractions or traumatic injury occurring during seizures
• Death is more likely to occur during an underlying disease responsible for the seizure
• Generalized seizures lasting for 30 to 45 minutes may cause necrosis of neurons and permanent neurological deficits.

Assessing Seizures

• Subjective data includes the patient's awareness of the disorder and any precipitating factors
• Assess whether an aura preceded the seizure.
• An aura occurs in about 50% of patient with generalized tonic-clonic seizures
• It is a sensation or emotion such as light, warmth or fear that may come before migraine or a seizure
• Aura are unique to the individual
• Some auras are psychic while others are sensory with olfactory, visual, auditory or taste hallucinations
• Objective data includes the number of seizures in a time frame, seizure character and behaviors of the patient
• Describe the seizure as much as possible including duration, patient movement, incontinence, sounds, level of alertness
• Assessment during seizures incorporate the neurological, respiratory, and cardiovascular systems.
• Characteristics of the seizure and the neurological state pre, during and post seizure must be identified
• Information collected including precipitating factors, auras, movements, automatisms, pupil size, eye deviation, responsiveness, LOC, incontinence, behaviours, weakness, injuries and duration
• Assess respiratory status and SpO2 for proper oxygenation as pulmonary edema can occur. Have suction and oxygen ready.
• Cardiac monitoring is necessary to assess for dysrhythmias.
• Assess blood glucose as hypoglycemia is a cause of SE.

Diagnosing Seizures

• Tests include blood and toxicology screening for infection or chemical imbalances
• Serum electrolytes, liver function, serum medication levels, blood and urine toxicology screens
• CT and MRI are done to assess lesions or location of seizure activity
• PET scans are done to pinpoint brain abnormalities
• EEG is most common. It allows a specific diagnosis of the seizure.

Treating Seizures

• 70% of patients with seizure disorders are controlled by antiseizure drugs in Table 54.6
• Therapy prevents seizures, it doesn't cure
• Drugs stabilize nerve cell membranes and prevent spread of the epileptic discharge
• Choice of medication depends on seizure type
• Not taking the medication or the appropriate dose causes treatment failure
• Blood levels are checked to determine therapeutic drug levels
• Main goal is obtain maximum control with minimum side effects
• Pharmacologic therapies cannot always control seizure activity
• SE must be treated immediately. Secure airway and breathing at all times.
• Medications are administered via a sequential approach that progressively uses more potent medications

Drug Information For Seizures

• First line medication is a benzodiazepine such as IV Lorazepam (Ativan)
• Levetiracetam (Keppra), Phenytoin (Dilantin), Fosphenytoin (Cerebyx), lamotrigine (Lamictal) or lacosamide (Vimpat) may be administered if Lorazepam don't stop activity in 10 minutes.
• If SE continues give propofol (Diprivan). May require intubation, assess for hypotension
• Surgery removes tissue misfiring leading to seizures or severing connective tissue between brain hemispheres. This is called reception.

Nursing Interventions For Seizures

• Management has a core focus of maintaining a patent away
• Providing adequate oxygenation
• Maintaing vascular acess for giving fluids and medicine
• Giving appropriate medications
• Taking caution to potential seizures
• Teach the patient to keep taking their medications even if the seizure activity has stopped
• Teach patient about the medications including expected result, time and dosage, along with side effects
• Patient can inform people medical alert bracelets are available
• Caution the patient from using alcohol while taking antiseizure medicine
• Good oral hygiene has to be explained if taking phenytoin (Dilantin), a side effect is gingival hyperplasia
• Stress the importance of adequate rest and eating a well balanced diet
• Educate availability of community resources
• Explain driving restrictions
• Explain importance of follow up care
• Tonic clonic seizures are treated with first aid, hospitals don't need to be involved past a single seizure unless prolonged, another seizure ensues or significant injury takes place
• In the event of an acute seizure the patient should be protected from injury

Treating a Seizure

• Position the patient appropriately to facilitate a patent airway, using an oral or nasal airway or endotracheal tube when needed
• Never put anything around teeth of a seizing patient.
• Suction to remove secretions, administer O2
• Use neuromuscular blocking medications to facilitate intubation, but understand that these interventions will to be effective in halting neuronal firing
• Nasogastric tube with intermittent suction to avoid airway compromise with apsiration
• Specific medication depends on seizure type and duration
• Must monitor BP , administer volume replscement and vaso active medications
• Theamine may be given prior to glucose if Wernicke's encephalopathy is suspected.

Nursing Actions During Seizure

• Protection from aspiration and injury
• Recording and keeping documented seizure activity
• Never leave the patient, lower them to the floor from sitting or standing
• Support the head, turn it to maintain airway, loosen constrictive clothing around the neck
• Don't try and pry open the jaw
• Padding side rails is a possible safety action
• After a seizure they may need suctioning and oxygen
• Observe and record the details of the even as the diagnosis and treatment hinges on the event's description
• Keep the bed low with side rails up when providing care for the patient

Patient Inability to Clear Airway

• Place in Side lying Position and suction when needed.

Potential for Injury

• Assist the patient to the floor and remove harmful items
• Maintain airway
• After seizure, inform patient of the seizure and reorient if necessary.

Other patient possible problems

• Impaired tissue perfusion
• Decreased gas exchange
• Ineffective airway clearance
• Disturbed thought process from the postictal state
• Need for health teaching
• Know that seizures and epilepsy have impacts of emotional, economic, and social dimensions
• While it has improved, social stigma is still an issue
• Most states have legal consequences if driving with epilepsy
• Inability to get a drivers license can have negative effects on ones lifestyle
• With most seizure disorders the number and intensity stay about the same
• The prognosis is more difficult with other brain pathologic conditions
• Degenerative diseases refer to neurologic disorders of premature aging of nerve cells. Examples include multiple sclerosis (MS), Parkinson's, Alzheimer's (AD), myasthenia gravis (MG), amyotrophic lateral sclerosis (ALS), and Huntington's.

Multiple Sclerosis

• MS is a chronic progressive degenerative neurologic disease
• The cause is unknown, there are genetics
• Patients may have proliferation of immune cells calles gamma delta T cells in their spinal fluid
• Initial cause may have been a viral infection that acts as an immune process
• Symptoms happen intermittently and so the disease may not be diagnosed until it's been happening for months or years
• Sings and Symptoms in MS are Greater vs other neurological diseases
• Visual problems
• Urinary incontinence
• Fatigue
• Weakness
• Impotence
• Swallowing difficulties
• Remissions can last a year or more
• There can be chronic progressive deterioration for some, remissions and exacerbations for others
• Exacerbations may pertain to fatigue, chilling, or emotional disturbances

Assessing MS

• Subjective data includes the patient's own understanding of the disease
• Visual eye problems such as diplopia
• Scotoma is a partial loss of vision like blindness
• The patient may recall weakness, numbness, fatigue or emotional imbalance
• Cerebellum may cause ataxia or tremor
• Men may recall impotance
• Objective data involves abnormalities in neurological testing such as nystagmus, muscle weakness, spasms, coordination or spastic

Cerebellar Signs in MS

• Ataxia
• Dysarthria
• Dysphagia
• Can be behavioral changes such as euphoria, emotional lability, mild depression
• Urinary incontinence and intentional tremors of upper extremeties

Diagnosing and Treating MS

• Multiple Sclerosis has no definitive diagnostic test
• Diagnosis based off history, clinical manifestation and the presence of multiple lesions over time
• Spinal tap of people may show elevated gamma globulin
• CT scan may show cerebral ventricles
• MRI has been helpful in diagnosis over time
• Sclerotic plaques be detected as small as 3-4mm
• Multiple Scleoriss has no specific treatment, just many tried remedies
• Treatment for symtoms involves adrenocorticotropic harmone and corticosteroids

Actionable Teaching Pointers For MS

• A well balanced diet of fiber and plenty of water is key
• Not one prescribed diet, but vitamins are recommended
• Obesity makes it hard to maintain mobility
• Referral to a dietician if obesity occurs
• Teach proper skin care for turning with caregivers
• Encourage exercising but not to fatigue
• Exercise decreases spasticity, increases coordination, exercise in water is a positive type of exercise
• Ensure daily rest, an acute exacerbation may cause patients to be quiet
• Stabilize gate by leaning towards the side that is less involved
• Tell a person with dropping foot to put it down and roll the side
• Hot baths aren't recommended
• Travel should be in the coolest parts of the day

Nursing Interventions For MS

• The patient may have slow speech and be slow with responses
• Sudden explosive emotional outbursts with crying can occur
• Caregivers provide emotional support, thorough explanations, reassurance
• They are alert to emotional changes and mood swings
• Encourage the expression of needs and feelings
• Maintain planed rest periods
• Encourage self care as indicated
• Provide physical care
• Assist the patient to do physical hygiene when able
• Administer oral hygiene as needed
• Institute bowel and bladder control programs
• Assist patient in dressing and grooming as indicated
• Provide nutritious and attactive meals

Patient Education For MS

• Teaching for signs and symptoms with siginicant others
• Important points are motor and sensory problems
• Late stages of the disease makes care unctions assumed by others
• Variable proganosis, some have deficits while others debilitate
• Life Expectancy is over 25 years from initial onset of symptoms
• Exacerbations are treated and may resolve.

Parkinson's Disease

• Syndrome that is a slowing in initiation and execution of movements, increased rigidity, tremor and impaired postural reflexes
• Other disorders may match this disease, known drug induced parkinsonism, postencephalitic parkinsonism, and arteriosclerotic parkinsonism
• These include drug-induced parkinsonism, postencephalitic parkinsonism, and arteriosclerotic parkinsonism.
• Parkinson's affects more than 1 million Americans
• Parkinson's has no known cure, but appears genetic. Rare in African Americans
• More common in men by a factor of 3/2.
• Encephalitis lethargic or type A encephalitis might cause parkinsonism
• parkisonism may be cuased by intoxication of monoxide and manganese

Clinical Manifestations of Parkinson's Disease

• Gradual and unsidious onset and progression. Initially only a mild tremor, handwriting changes, a light limp may be evident.
• Can later cause a shuffling gait, flexed arms and loss of postural reflexes.
• The diagnosis is based on history and neurologic exam and symptoms
• Tremor, Rigiditiy, Bradykenesia(slow and or retarded movment)
• Cognitive function will degrade and cause dementia
• A positive response to carbidopa is a sign
• handwriting trails off tremore
• tremor at rest but goes away with movement or stress/ increased concentration
• hand tremor rolls like pill

Additional Info on Parkinson's Disease

• Rigidity is increased passive motion limits
• Jerky like ratcheting
• Cogwheel rigidity
• Muscle tire sore
• Bradykenesia

Assessing Parkinsons Symptoms

• Fatigue
• Incoordination
• judgement defects
• emotional instability
• anxiety
• depression
• heat intolerance
• Objective
• tremor like a pill
• Masklike appearance
• dysphasia
• oily skin
• postural hypotension
• Parkinsons has no tests

Treating Parkinson's Disease

• ease symptoms
• Drug side effects is dyskinesia, so a drug holiday can help
• Surgery is destroying regions of brain, but now DBS for the brain is used
• Placed electrode to place the generator on chest is DBS

Nursing Considerations for Parkinson's

• Activity posture is key!
• Lie withought pillow
• Hands behind back
• freeze is an issue with walking, freeze happens a lot

Nursing Actions With Parkinson's Patients

• Make sure chairs help rise
• Diet is key!
• Malnutrition
• Easy to chew stuff
• 6 small meals
• Be very careful when feeding!
• Drooling can be problem
• Urgency
• Stool Softeners, prune, get the patient to take care of themselves
• Need to assess risk, do ROM exercises, help with walking, speech therapy

Patient Education On Parkinson's Disease

• Important of meds being taken on time is key in education
• Need good skin, stay active, demostrate and position the family
• Teach feeding and reduce and reduce breathing issues

Misc Parkinson's Deisease Info

• There isn't a cure! It is chronic
• Symptoms contsrolled for long
• Care can fall to family members

Alzheimer's Disease

• Alzheimer's is a chronic and degenerative order that affects brain cells and causes impaired intellectual functionality
• Plaques in cortex
• Neurofibrillary tangles
• Loss between connections
• Damage on cerebral cortex
• Decreaed brain size
• Less of a risk by learning and information processing stuff

Clinical Manifestations of Alzheimer's

• Progression as 4 stages, loss of correct word
• Attention span becomes desensitized, depression too. Memory goes.
• Disoriented to time, memory slips
• Hallucinations, loss of impulse control and recognition
• Sundowning which leads to agitated
• Apraxiia
• Visual angiosa
• Writing is impacted
• Wandering and severe decline occurs

Assesing Alzheimer's Disease

• Memory Loss with AD
• Disturbs daily lift
• Planning or solving problems
• images messed up
• new problems saying words wrong
• misplaced step

Alzheimer's Nursing Intervention

• No medicine exists to treat, but anti depressants may help
• Memantine slows memory loss, nut slows
• Nutrients are in special need

Nursing Interventions for Memory Loss in Alzheimer's Patients

• Stay active
• Safety is key, stove on
• No effective treatment
• Special care can help with being produtive
• The cost is a taggering cost, its a social care problem

MS (Myasthenia Gravis)

• Autoimmune
• A person has 1/3d of as normal
• Eyelid Drooping or double vision is ocular

Medical Care and More

• It can happen
• Muscle weakness becomes severe
• Meds, promote nerve
• Steroid is adjunct
• No quinies for patients with MG

Action points with Nurses caring for patients

• They might need intubation
• Breathing
• Treat respiratory
• Diaphragm
• Educations to keep energy usage down

Amyotrophic Lateral Sclerosis

• 2/6 year death rate
• upper and lower are bad
• Weakness
• Fasciculations
• Death resp

Huntington's Disease

• Genetic transmitted
• Involuntary Movements
• Chewing affected
• Gait is destroyed
• Hallucinations/psychosis
• Antipsychotics and anti chorea (antirepression) can help
• Nutritious and Psychological supports
• 500 cal reqs-

Stroke - 1,4 minutes deprived brain dies

• Blood
• Hemorrhagic, blood

What happens during a stoke?

• Hemiparesis
• Aphasia

Types of Strokes

• Hemorrhagic or ischameic

Risk Factors Of Stroke

• Atherosclerosis, A-Fib, Cardiac Diesease, Diabetes
• Low dose birth
• Meds are Stroke factor, A fib
• Carotid Artery Stenosis-Build up
• Symptoms happen faster for sleep as they sleep

Info For Stroke

• Types
• Thrombolic , Embolic

Assessing Strokes

• Subjective (Pain - tingling etc)
• objective, hemiplegia, change in alertness, respitory

Action during stroke

• If not there remove blood
• There is not one side so there is no speaking is lost
• Can't remove blood in middle etc
• Surgery Clip
• Endo cathetars
• Get them running

How To Check For a Stroke

• Check and act like one in fast (check face, arms, speak, time)
• Reduce by 30 in early minutes

Nursing Care for Strokes

• Nuero checks
• Safety
• Teaching
• Talk slow during stroke

Medical Terms and Stroke

• Apoaxia
• Gnosia - can't recognize
• Hemianopia - cut half vision
• Aphasia - lost speech Box 14.1 - Stroke

More About Strokes

• Long deficts, homonomy
• Dominant language to speak
• Expressive with no sounds
• Receptive - can't hear with sounds

Medical care after strokes or what could happen

• Rebleed, prevent
• Catherized for stroke
• 27-37 get good care
• Side of body moves at stages
• Get patient good as possible to walk
• May be lost of body picture
• Emotional issues are lost Help with word lost

Education

• Know what is gone from you
• Therapy

During a Stroke Care

• Nutrition , swallow, position heads side
• Have food in mouth to spit put
• Side of face is safe
• Patient is key to the stroke

Ischemic or Hemorrhagic

• Hem is lost
• Ischaem - blockage

Medical Side

• Give aspirin
• Orwarfria

Diagnostic Testing of Stroke

• Subjective
• Hemiparesis
• Respitory Aphasia
• Cut body side.