Nursing Care of Patients With Central Nervous System Disorders PDF

4068_Ch48_1118-1170 18/11/14 4:44 PM Page 1118 48 Nursing Care of Patients With Central Nervous System Disorders KEY TERMS...

4068_Ch48_1118-1170 18/11/14 4:44 PM Page 1118 48 Nursing Care of Patients With Central Nervous System Disorders KEY TERMS DEBORAH L. WEAVER akinesia (AH-kin-EE-zee-uh) ataxia (ah-TAK-see-ah) bradykinesia (BRAY-dee-kin-EE-zee-ah) LEARNING OUTCOMES contralateral (KON-truh-LAT-er-uhl) 1. Explain causes, risk factors, and pathophysiology of craniectomy (KRAY-nee-EK-tuh-mee) cranioplasty (KRAY-nee-oh-plas-tee) central nervous system infections, including meningitis craniotomy (KRAY-nee-AHT-oh-mee) and encephalitis. delirium (de-LEER-ee-um) 2. Plan nursing interventions for a patient with a central dementia (dee-MEN-cha) nervous system infection. dysreflexia (DIS-re-FLEK-see-ah) encephalitis (en-SEFF-uh-LYE-tis) 3. Differentiate between the various types of headaches. encephalopathy (en-SEFF-uh-LAHP-ah-thee) 4. Identify teaching you will provide for a patient hemiparesis (hem-ee-puh-REE-sis) experiencing headaches. hydrocephalus (HEYE-droh-SEF-uh-luhs) ipsilateral (IP-si-LAT-er-uhl) 5. List the causes and types of seizures. laminectomy (LAM-i-NEK-toh-mee) 6. Describe appropriate interventions for an individual meningitis (MEN-in-JIGH-tis) neurodegenerative (new-roh-de-JEN-er-uh-tiv) experiencing a seizure. nuchal rigidity (NEW-kuhl re-JID-i-tee) 7. Recognize a patient who is developing increased paraparesis (PAR-ah-puh-REE-sis) intracranial pressure. paraplegia (PAR-ah-PLEE-jee-ah) photophobia (FOH-tuh-FOH-bee-ah) 8. Identify nursing interventions that can help prevent postictal (pohst-IK-tuhl) increased intracranial pressure. prodromal (proh-DROH-muhl) 9. Explain the causes, risk factors, and pathophysiology quadriparesis (KWA-dri-puh-REE-sis) of injuries to the brain and spinal cord. quadriplegia (KWA-dri-PLEE-jee-ah) turbid (TERR-bid) 10. Plan nursing care for a patient with an injury to the brain or spinal cord. 11. Explain causes, risk factors, and pathophysiology associated with neurodegenerative disorders such as Parkinson’s, Huntington’s, and Alzheimer’s diseases. 12. Plan nursing care for a patient with a neurodegenerative disorder. 13. Plan nursing interventions for the patient with dementia. 1118 4068_Ch48_1118-1170 18/11/14 4:44 PM Page 1119 Chapter 48 Nursing Care of Patients With Central Nervous System Disorders 1119 Disorders of the central nervous system (CNS) include prob- invades the CNS, causing the meninges to become inflamed lems originating in the brain and spinal cord. Because the CNS and intracranial pressure (ICP) to increase. Vessel occlusion is the control center for the entire body, disorders in this sys- and necrosis of areas in the brain can occur. Cranial nerve tem can cause symptoms in any part of the body, ranging from function can be transiently or permanently affected by menin- pain to confusion, paralysis, and coma. This chapter presents gitis. Some of the effects are listed in Table 48.2. nursing care of patients with these disorders. Care of patients with cerebrovascular disorders is covered in Chapter 49. Prevention Vaccines are available against some pathogens. Hib vaccina- tions are begun during infancy. A vaccine against S. pneumo- CENTRAL NERVOUS SYSTEM INFECTIONS niae is recommended for people o ver age 65 and those who have a chronic medical condition. Currently the Centers for Infectious agents can enter the CNS via a v ariety of routes Disease Control and Prevention (CDC) recommends 2 doses (Table 48.1). Anything that depresses the patient’ s immune of meningococcal vaccine (MCV4) for adolescents, one at age system such as steroid administration, chemotherapy, radia- 11 or 12 and a booster at age 16. Other groups at increased tion therapy, or malnutrition can mak e the patient more risk who should be vaccinated are college freshmen living in vulnerable to infection. dormitories, U.S. military recruits, anyone with compromised Meningitis immunity, laboratory personnel, and those tra veling to areas of the world where meningococcal disease is common. Pathophysiology and Etiology Chemoprophylaxis is recommended for those who ha ve Meningitis is an inflammation of the meninges that surround had significant exposure to anyone currently infected with the brain and spinal cord. It can be caused by either bacterial meningitis. To destroy the organism from the nasopharynx, or viral infection. Any microorganism that enters the body antimicrobials such as rifampin, quinolones, or sulfonamides can result in meningitis. Bacterial meningitis is a serious are used. infection that is spread by direct contact with discharge from the respiratory tract of an infected person. Viral meningitis, Signs and Symptoms also called aseptic meningitis, is more common and rarely The most common symptom of meningitis is a se vere serious. It usually presents with flulik e symptoms, and headache, caused by tension on blood v essels and irritation patients recover in 1 to 2 weeks. of the pain-sensitive dura mater. A high fever and stiff neck The most common bacteria causing meningitis include are present, and the patient may e xperience photophobia Neisseria meningitidis, Streptococcus pneumoniae, and (light sensitivity). The patient with meningococcal meningitis Haemophilus influenzae type b (Hib). With current immu- usually presents with petechiae on the skin and mucous mem- nization standards in the United States, H. influenzae type b branes. has decreased in recent years. N. meningitidis, the cause of Nuchal rigidity (pain and stif fness when the neck is meningococcal meningitis, and S. pneumoniae, the cause of moved) is caused by spasm of the e xtensor muscles of the pneumococcal meningitis, are the major causes of bacterial neck. Positive Kernig’s and Brudzinski’s signs are often seen meningitis. Bacterial infection generally be gins in another in patients suffering from meningitis. Both signs are caused area, such as the upper respiratory tract, enters the blood, and by inflammation of the meninges and spinal nerv e roots. To elicit Kernig’s sign, the examiner flexes the patient’s hip to TABLE 48.1 ROUTES OF ENTRY FOR WORD BUILDING CENTRAL NERVOUS SYSTEM meningitis: mening—membranous covering of the brain + itis— INFECTIONS inflammation photophobia: photo—light + phobia—fear or intolerance Route of Entry Examples Bloodstream Insect bite Otitis media TABLE 48.2 CRANIAL NERVES Direct extension Fracture of frontal or facial bones AFFECTED BY MENINGITIS Cerebrospinal Dural tear fluid Poor sterile technique during Cranial Nerve Affected Manifestation procedure III, IV, VI Ocular palsies Unequal and sluggishly Nose or mouth Meningococcus meningitis reactive pupils In utero Contamination of amniotic fluid VII Facial weakness Rubella Vaginal infection VIII Deafness and vertigo 4068_Ch48_1118-1170 18/11/14 4:44 PM Page 1120 1120 UNIT THIRTEEN Understanding the Neurologic System 90 degrees and tries to extend the patient’s knee. The sign is (MRI) or computed tomographic (CT) scan can be done to positive if the patient experiences pain and spasm of the ham- evaluate for complications. string. Brudzinski’s sign is positive when flexion of the pa- tient’s neck causes the hips and knees to fle x (Fig. 48.1). Therapeutic Measures Nausea and vomiting associated with meningitis are caused Antibiotics such as penicillin G, v ancomycin, and by direct irritation of brain tissue and by increased ICP. cephalosporins are administered for bacterial meningitis. It is Encephalopathy refers to the mental status changes seen important to note the sensitivity report when it is complete to in patients with meningitis. These are manifested as short confirm the antibiotic in use is the best choice because there attention span, poor memory, disorientation, difficulty fol- has been an increase in antibiotic/antimicrobial-resistant lowing commands, and a tendency to misinterpret environ- strains. Symptom management is the same for viral or bacterial mental stimuli. Late signs of meningitis include lethar gy meningitis. Antipyretics such as acetaminophen are used to and seizures. control the fever; a cooling blank et also can be used. Care should be taken to avoid cooling the patient too much because Complications shivering increases the metabolic demand for oxygen and glu- Resolution of meningitis depends on how quickly and effec- cose. Analgesics are given to lessen head and neck pain. Cor- tively the disease is treated. Viral meningitis usually has no ticosteroids and anti-inflammatory agents are given to decrease lasting effects; however, bacterial meningitis can be f atal. swelling. Nausea and vomiting are controlled with antiemetic Cranial nerve damage can lea ve the patient blind or deaf. medications. The patient with meningococcal meningitis Seizures can continue to occur even after the acute phase of should be placed in isolation for at least the f irst 24 hours of the illness has passed. Cognitive deficits ranging from mem- medication administration to prevent transmission to others. ory impairment to profound learning disabilities can occur. Patients can become agitated. A quiet, dark environment lessens the stimulation of a patient who has a headache or Diagnostic Tests photophobia and who is agitated, disoriented, or at risk for A lumbar puncture is the most informati ve diagnostic test seizures. An important aspect of nursing care focuses on for a patient with suspected meningitis (see Chapter 47). keeping patients from harming themselv es. It is very upset- Viral meningitis is characterized by clear cerebrospinal fluid ting to families to see a lo ved one acting agitated or disori- (CSF) with normal glucose level and normal or slightly in- ented. Therefore, it is important to teach the f amily about creased protein level. No bacteria are seen, b ut the white symptoms and treatment goals for the patient (Table 48.3). blood cell (WBC) count is usually increased. In contrast, the CSF of an individual with bacterial meningitis is turbid, Encephalitis or cloudy, because of the ele vated number of white blood Pathophysiology cells. Bacteria are identified by Gram stain and culture, and Encephalitis is an inflammation of brain tissue. Nerv e cell a sensitivity test is done to identify the most ef fective an- damage, edema, and necrosis cause neurologic f indings lo- tibiotic. The bacteria use the glucose normally found in calized to the specific areas of the brain affected. Hemorrhage CSF, thereby lowering the glucose level. The amount of pro- in the brain can occur in some types of encephalitis. Increased tein in the CSF is ele vated. A magnetic resonance image ICP can lead to herniation of the brain (see later section on increased ICP). Etiology Pain Viruses are the most common cause of encephalitis.They can be specifically related to a particular time of year or geo- graphic location. Some viruses, such as West Nile virus, are carried by ticks or mosquitoes. Others are systemic viral in- fections, such as infectious mononucleosis or mumps, which spread to the brain. Parasites, toxic substances, bacteria, vac- cines, and fungi are other potential causes of encephalitis. Herpes simplex is the most common non–insect-borne virus to cause encephalitis. The majority of individuals harbor A Kernig’s sign herpes simplex virus type 1 in a dormant state. This is the virus responsible for sores on the oral mucous membranes, commonly called cold sores. Communicable diseases, fever, and emotional stress are possible reasons for the virus becoming active, but the exact mechanism is not known. B WORD BUILDING Brudzinski’s sign encephalopathy: encephalo—brain + pathy—illness FIGURE 48.1 (A) Kernig’s sign. (B) Brudzinski’s sign. encephalitis: encephalo—brain + itis—inflammation 4068_Ch48_1118-1170 18/11/14 4:44 PM Page 1121 Chapter 48 Nursing Care of Patients With Central Nervous System Disorders 1121 motor deficits, and blindness can also occur. Deterioration in TABLE 48.3 MENINGITIS SUMMARY cognition and personality changes are particularly stressful for significant others. The patient’s behavioral control is a Signs and Nuchal rigidity major factor in determining dischar ge plans. You can assist Symptoms Positive Kernig’s and Brudzinski’s significant others to realistically assess the patient’ s func- signs tional level and the family’s ability to care for the patient. In- Fever home care, outpatient therapy, and adult day care are options Photophobia to explore. For some severely impaired individuals, custodial Petechial rash on skin and mucous care may be the only feasible and safe discharge option. membranes Encephalopathy Diagnostic Tests CT scan, MRI, lumbar puncture to obtain CSF, and electroen- Diagnostic Lumbar puncture with CSF analysis, cephalogram (EEG) are used to diagnose encephalitis. CSF Tests culture and sensitivity (C&S) analysis typically reveals increased WBC count and protein Complete blood count level and normal glucose le vels. Breakdown of blood after C&S nose and throat cerebral hemorrhage results in yello w-colored CSF. Viral Therapeutic Antimicrobials (if bacterial) serology can be useful to identify the type of virus and guide Measures Seizure precautions treatment options. Antipyretics Pain management Therapeutic Measures Reduction of environmental stimuli No specific treatment is currently available for insect-borne Education encephalitis. Careful neurologic assessment and treatment of symptoms can help pre vent complications and impro ve Complications Seizures survival. Anticonvulsants, antipyretics, and analgesics are Increased ICP administered to reduce seizures, fever, and headache. Corti- Hearing loss costeroids are used to decrease swelling from inflammation. Vision impairment Sedatives may be given for irritability. Antiviral medications Cognitive defects such as acyclovir (Zovirax) may also be used, especially for Possible Hyperthermia herpes simplex. Nursing Acute Pain related to nuchal rigidity Diagnoses Risk for Injury related to positive INCREASED INTRACRANIAL PRESSURE culture in CSF Pathophysiology and Etiology CSF = cerebrospinal fluid; C&S = culture and sensitivity; ICP = intracranial pressure. Any patient with a pathological intracranial condition is at risk for increased ICP. ICP is the pressure exerted inside the cranial cavity by its components (blood, brain, and CSF). Signs and Symptoms Normal ICP is 0 to 15 mm Hg. This pressure fluctuates with As with many viruses, there is a period of headache, general normal physiological changes, such as arterial pulsations, malaise, nausea and vomiting, and fever. These symptoms changes in position, and increases in intrathoracic pressure usually develop over a period of se veral days. Additional (e.g., coughing or sneezing). Common causes of increased symptoms include nuchal rigidity, confusion, decreased level ICP include brain trauma, intracranial hemorrhage, and brain of consciousness, seizures, photophobia, ataxia (lack of mus- tumors. Prompt detection of changes in neurologic status cle coordination), abnormal sleep patterns, and tremors. The indicating increased ICP allows intervention aimed at pre- patient may also have hemiparesis (slight paralysis or weak- venting permanent brain damage. ness on one side of the body). The skull is a rigid compartment containing three compo- The patient with herpes encephalitis develops edema and nents: brain, blood, and CSF. If an increase in one component necrosis (sometimes associated with hemorrhage), most com- is not accompanied by a decrease in one or both of the other monly in the temporal lobes. This significant cerebral edema components, the result is increased ICP (Fig. 48.2). The con- causes increased ICP and can lead to herniation of the brain. sequences of increased ICP depend on the degree of elevation If the patient becomes comatose before treatment is be gun, and the speed with which the ICP increases. Patients with slow- the mortality rate can be as high as 70% to 80%. The first growing tumors can have significantly increased ICP before 72 hours is the most likely time for death to occur due to the they develop symptoms. Conversely, patients with a subarach- cerebral edema. noid hemorrhage can sustain a sudden sharp increase in ICP. Complications Patients who have had encephalitis are often left with cogni- WORD BUILDING tive disabilities and personality changes. Ongoing seizures, hemiparesis: hemi—one side + paresis—partial paralysis 4068_Ch48_1118-1170 18/11/14 4:44 PM Page 1122 1122 UNIT THIRTEEN Understanding the Neurologic System Brain Intravascular of these methods requires anesthetizing the scalp and blood drilling a hole, called a burr hole, into the skull. Placement of a catheter into one of the lateral v entricles is referred to as external ventricular drainage (Fig. 48.3). This method allows for pressure monitoring as well as drainage of CSF to reduce ICP. Disadvantages to this method include dif- ficulty in locating the v entricle for insertion of the catheter and clotting of the catheter by blood in the CSF. To allow communication with the subarachnoid space, a subarachnoid bolt can be tightly scre wed into the burr hole after the dura has been punctured (Fig. 48.4). The advantage of a subarachnoid bolt is ease of placement. Disadv antages include occlusion of the sensor portion of the bolt with brain tissue and inability to drain CSF. An intraparenchymal mon- Cerebrospinal itor is placed directly into brain tissue. Some physicians be- fluid lieve that this most accurately reflects the actual situation FIGURE 48.2 Any increase in brain tissue, blood, or cere- within the skull. These monitors cannot be used to drain CSF brospinal tissue can increase intracranial pressure. and can become occluded by brain tissue. Patients with ICP monitors are cared for in an intensi ve care unit (ICU) and require aggressive nursing care to prevent The normally functioning body has se veral methods of complications. These patients are often mechanically v enti- compensating for increased ICP. CSF can be shunted into the lated and may be pharmacologically paralyzed and sedated. spinal subarachnoid space. Hyperventilation can trigger con- In addition to meeting the patient’s physiological needs and striction of cerebral blood v essels, decreasing the amount preventing complications, education and emotional support of blood within the cranial vault. These compensatory mech- for significant others is important. anisms are temporary and not particularly ef fective if the Nursing Process for the Patient increase in ICP is sudden or severe. With a Communicable or Signs and Symptoms Inflammatory Neurologic Disorder Initial symptoms of increased ICP include restlessness, irri- Data Collection tability, and decreased level of consciousness because cere- Collaborate with the registered nurse (RN) to obtain a com- bral cortex function is impaired. If not intubated, the patient plete history from the patient, if feasible, and from significant can hyperventilate, causing v asoconstriction as the body others. Pay particular attention to e xposure to risk f actors. attempts to compensate. As the pressure increases, the ocu- The physical examination must include all body systems be- lomotor nerve can be compressed on the side of the impair - cause neurologic impairment affects the entire person. F ol- ment. Compression of the outermost fibers of the oculomotor lowing the initial examination, serial neurologic assessments nerve results in diminished reactivity and dilation of the pupil. continue to be important to detect and report changes As the f ibers become increasingly compressed, the pupil promptly. You can assist with monitoring pupil response, stops reacting to light. If the compression continues and the level of consciousness (LOC), and vital signs for signs of in- brain tissue exerts pressure on the opposite side of the brain creased ICP (Box 48-1). Monitor headache on a pain scale if from the injury, both pupils become fixed and dilated. the patient is able to participate. The Glasgow Coma Scale Vital sign changes are a late indication of increasing ICP. Cushing’s triad is a classic late sign of increased ICP and is Catheter into characterized by bradycardia, irregular respirations, and ar- ventricle terial hypertension (increasing systolic blood pressure while diastolic blood pressure remains the same), resulting in widening pulse pressure. By the time these symptoms appear, the ICP is significantly increased and interventions may not be successful. Monitor Monitoring ICP monitoring allows for early detection of changes in the CSF drainage pressure on the brain, before changes in symptoms are seen. The most common method of monitoring ICP in adults is by placing a catheter in the v entricle of the brain, in the FIGURE 48.3 Ventricular drain. A catheter into the ventricle cerebral parenchyma, or in the subdural or subarachnoid allows intracranial pressure monitoring and cerebrospinal fluid space. This can be done at the bedside or in sur gery. Each drainage. 4068_Ch48_1118-1170 18/11/14 4:44 PM Page 1123 Chapter 48 Nursing Care of Patients With Central Nervous System Disorders 1123 Scalp Skull Dura mater Arachnoid Subarachnoid space Syringe Three-way stopcock Subarachnoid Transducer screw Close-up of placement into subarachnoid space FIGURE 48.4 Subarachnoid bolt monitor. or the FOUR Score, presented in Chapter 47, are v aluable tools to monitor level of consciousness. Box 48-1 Signs and Symptoms of Nursing Diagnoses, Planning, and Implementation Increased Intracranial The licensed practical nurse/licensed v ocational nurse Pressure (LPN/LVN) collaborates with the RN in implementing care. Vomiting For additional interventions for patients with communicable Headache or inflammatory disorders, see the “Nursing Care Plan for the Dilated pupil on affected side Patient With a Brain Tumor or Injury.” Hemiparesis or hemiplegia Decorticate then decerebrate posturing Patient Education Decreasing level of consciousness The nature and focus of teaching depend on the patient’s level Increasing systolic blood pressure of consciousness and cogniti ve status. When appropriate, Increasing then decreasing pulse rate both the patient and significant others should be included in Rising temperature the education process. If the patient is not able to participate, the significant others become the focus of teaching. NURSING CARE PLAN for the Patient With a Brain Lesion or Injury Nursing Diagnosis: Hyperthermia related to infectious process Expected Outcome: The patient will not exhibit evidence of hyperthermia. Evaluation of Outcome: Is temperature controlled? Intervention Assess temperature every 4 hours and as needed (prn). Rationale An elevated temperature can increase risk for seizures. Evaluation Is temperature controlled? Continued 4068_Ch48_1118-1170 18/11/14 4:44 PM Page 1124 1124 UNIT THIRTEEN Understanding the Neurologic System NURSING CARE PLAN for the Patient With a Brain Lesion or Injury—cont’d Intervention Administer acetaminophen or aspirin as ordered. Rationale Antipyretic agents reduce fever. Evaluation Are antipyretics effective? Intervention Provide a cooling mattress or tepid sponge baths as necessary. Rationale A cooling mattress may be necessary to reduce fever. These are uncomfortable for the patient. Comfort can be increased and shivering reduced by cooling the patient gradually and wrapping extremities in bath blankets during cooling mattress therapy. Evaluation Is cooling mattress or tepid bath effective? Is patient comfort maintained? Nursing Diagnosis: Risk for Acute Confusion related to cerebral edema and increased intracranial pressure Expected Outcomes: The patient will be oriented to person, place, and time; if this is not possible, patient’s safety will be maintained. Evaluation of Outcomes: Is patient oriented to self, place, and time and able to ask for help appropriately to prevent injury? Intervention Assess level of consciousness (LOC) using Glasgow Coma Scale or the FOUR Score. Rationale Change in LOC can indicate increased intracranial pressure and should be reported. Evaluation Is patient alert and responsive? Is LOC stable? Intervention Monitor orientation and reorient as needed. Rationale Giving correct information to patient will as- sist in orientation. Evaluation Can patient identify who he/she is, location, and month, year, or season? Intervention Observe patient’s reaction to simple commands such as “raise your hand.” Rationale This helps distinguish between reflexes and purposeful movement. Evaluation Is patient able to follow simple commands? Intervention Monitor patient’s capabilities as activities increase. Rationale Patient can experience dizziness, im- balance, and confusion; the patient will need assistance with mobilization until stable. Evaluation Can patient sit up and ambulate to chair without dizziness? Intervention If patient is not able to be reoriented, assess for safety and implement appropriate safety measures. Rationale Depending on the patient’s prognosis, orientation may not be a realistic goal. Evaluation Is patient’s safety maintained? Nursing Diagnosis: Self-Care Deficit, dressing/feeding/toileting, related to mental status changes and inability to perform ADLs independently Expected Outcome: The patient will maintain as much independence with ADLs as possible. Evaluation of Outcome: Is the patient able to participate in self-care at an appropriate level? Intervention Assess what the patient was able to do before admission/injury. Rationale The patient’s potential for participation will depend on what he or she was able to do before injury. Evaluation What was the patient able to do? How does that compare with what he or she can do now? Intervention Provide all supplies and equipment needed to carry out ADLs. Rationale Assembling equipment for the patient reserves energy for performing self-care. Evaluation Is the patient able to perform the majority of bath and hygiene tasks with appropriate setup? Intervention Encourage the patient to perform activities at own pace. Rationale The patient may need more time to perform activities. Evaluation Does the patient gradually increase performance of self-care in a timely fashion? 4068_Ch48_1118-1170 18/11/14 4:44 PM Page 1125 Chapter 48 Nursing Care of Patients With Central Nervous System Disorders 1125 NURSING CARE PLAN for the Patient With a Brain Lesion or Injury—cont’d Intervention Teach and encourage family to participate with care. Rationale Including the family in the patient’s care promotes support and family interaction. Evaluation Is the family involved? Is the patient accepting of their assistance? Intervention Refer to occupational therapy if indicated. Rationale An occupational therapist is trained to assist patients to manage ADLs within health limitations. Evaluation Is occupational therapist able to assist patient with strategies to maintain independence? Nursing Diagnosis: Acute/Chronic Pain related to cerebral edema and headache as evidenced by patient pain rating or evidence of painful behaviors Expected Outcomes: Patient’s pain is controlled as evidenced by statement that pain level is acceptable, or decrease in painful behaviors. Evaluation of Outcomes: Does patient state pain level is acceptable? Are pain behaviors reduced? Intervention Assess pain using a scale of 0 to 10 or PAINAD scale (see Chapter 10). Rationale The patient’s self-report is the best measure of the patient’s pain. Evaluation Is the patient able to rate pain? Is there evidence that pain is present? Intervention Monitor vital signs. Rationale Pulse and blood pressure can be elevated in acute pain. Evaluation Are vital signs elevated? Intervention Administer appropriate pain medication as ordered. Rationale Nonnarcotic medications are preferred because they do not alter the level of consciousness. If these are not effective, codeine preparations, which have a minimal effect on LOC, may be prescribed. Evaluation Does patient state pain has decreased? Is sedation minimized? Intervention Implement measures to reduce ICP. See Table 48.4 for measures and rationales. Rationale Increased intracranial pressure can increase pain. Evaluation Do measures to reduce ICP help prevent pain? Intervention Provide alternative comfort measures such as dim lights, a quiet environment, and positioning for comfort. Rationale Decreasing stimuli in the room by dimming lights and decreasing noise can have a calming effect. Evaluation Is patient resting quietly, with no evidence of pain? Nursing Diagnosis: Risk for Injury Secondary to Impaired Sensory Perception related to brain injury and cranial nerve involvement as evidenced by alterations in response to stimuli Expected Outcome: The patient will be kept safe from injury related to reduced sensation. Evaluation of Outcome: Is patient safe? Is skin intact? Intervention Monitor patient’s ability to perceive stimuli. Rationale Changes in patient’s perceptions must be incorporated into the plan of care. Evaluation What can the patient feel? Intervention Turn patient and assess skin at least every 2 hours while in bed; provide moisturizer as needed. Protect bony prominences. Rationale If the patient cannot determine pressure or dryness, the nurse must evaluate and act to prevent skin breakdown. Evaluation Is skin intact, pink, warm, dry, and without redness? Intervention Assist the patient out of bed and into a different environment. Rationale This can help prevent sensory deprivation and social isolation. Evaluation How does patient respond to being in a chair or wheelchair and taken to sunroom or common area? Continued 4068_Ch48_1118-1170 18/11/14 4:44 PM Page 1126 1126 UNIT THIRTEEN Understanding the Neurologic System NURSING CARE PLAN for the Patient With a Brain Lesion or Injury—cont’d Intervention Teach the patient to monitor own position and skin, and to direct position changes. Rationale This provides a way for the patient to maintain some control over his body and to take part in preventing complications. Evaluation Is patient able to direct care activities effectively? Nursing Diagnosis: Impaired Physical Mobility related to motor deficits as evidenced by weakness, inability to change position Expected Outcomes: The patient will maintain maximum mobility and be free from complications of immobility. Evaluation of Outcomes: Is patient kept mobile without contractures? Is skin intact? Intervention Assess degree of mobility limitation. Rationale A good assessment can help determine how much the patient can actively participate in a plan for mobilization. Evaluation How much can patient do independently? Is physical/occupational therapy evaluation indicated? Intervention Turn patient every 1 to 2 hours; if postoperative, avoid positioning on the operative site unless specifically permitted by the surgeon. Rationale Turning helps prevent skin and respiratory complications. Evaluation Is a turning schedule maintained? Is skin free from redness and breakdown? Intervention Position patient in correct body alignment. High-top tennis shoes, trochanter rolls, and slings can be used to keep the body in alignment. Rationale This keeps the patient in functional position in case function is regained in the future. Evaluation Are all joints maintained in correct alignment? Intervention Perform range-of-motion (ROM) exercises; consult physical therapy as ordered. Rationale ROM exercises help prevent contractures. Evaluation If patient unable to perform active ROM exercises, are passive ROM exercises provided on a regular schedule? Intervention Consult occupational therapist to assist the patient in learning to perform ADLs. Rationale The patient may be able to participate in self-care with assistive devices. Evaluation Do assistive devices help patient mobilize and maintain independence? Nursing Diagnosis: Risk for Injury related to seizures Expected Outcome: The patient will remain free of injury if a seizure occurs. Evaluation of Outcome: Is safety maintained? Is skin intact, without bruising or discoloration? Intervention Observe the patient’s behavior and time the length of the seizure. When patient is alert following seizure, determine if an aura occurred, and what it was. Rationale Observing the seizure can provide clues for teaching the patient to recognize the warning signs of a future seizure and how to maintain safety. Evaluation What did the patient experience? What can be taught to help keep patient safe in the future? Intervention If patient loses consciousness during the seizure, lay patient on his or her side or turn head to the side. Rationale This helps prevent oral secretions from being aspirated. Evaluation Did patient maintain a patent airway without respiratory distress? Intervention Remove objects from patient’s surroundings to prevent injury during a seizure. If the patient must have side rails, pad them with blankets or foam (see also Table 48.6, later in chapter). Rationale During a tonic- clonic seizure the patient can be harmed by hitting furniture or other objects. Evaluation Is patient protected from objects that could cause injury during a seizure? 4068_Ch48_1118-1170 18/11/14 4:44 PM Page 1127 Chapter 48 Nursing Care of Patients With Central Nervous System Disorders 1127 TABLE 48.4 MEASURES TO PREVENT INCREASED INTRACRANIAL PRESSURE Preventive Measures Rationale Keep head of bed elevated 30 degrees unless contraindicated. Head elevation reduces ICP in some patients. Avoid flexing the neck; keep head and neck in midline Neck flexion can obstruct venous outflow. position. Administer antiemetics and antitussives as necessary to Coughing and vomiting can increase ICP. prevent vomiting and cough. Administer stool softeners. Straining for bowel movement can increase ICP. Minimize suctioning. If absolutely necessary, oxygenate Suctioning can increase ICP. first and limit suction passes to one or two. Avoid hip flexion. Hip flexion can increase intra-abdominal and thoracic pressure, which can increase ICP. Prevent unnecessary noise and startling the patient. Noxious stimuli can increase ICP in some patients. Space care activities to provide rest between each disturbance. Clustering care activities can increase ICP. ICP = intracranial pressure. Describing the brain as in control of body functions can condition. If headaches are recurrent, persistent, or increasing help significant others to understand some of the symptoms in severity, the patient should under go a neurologic evalua- of neurologic disorders. The spinal cord can be compared to tion. This section addresses the most common types of a telephone cord, with hundreds of tin y individual wires headache. (nerves) making up the cord. The specific wires affected by disease determine the symptoms the patient experiences. Types of Headaches Headaches are divided into three major types: (1) primary , (2) secondary, and (3) cranial neuralgias, central and primary CRITICAL THINKING facial pain and other headaches. Primary headaches are dis- cussed in this section. Secondary headaches are caused by Mr. Chung trauma, infection, or other disorders. Cranial neuralgias are discussed in Chapter 50. F or more information visit the In - Mr. Chung is an 18-year -old Asian college student. ternational Headache Society at http://ihs-classification He comes to the emergency department with a headache,.org/en. Because the causes, signs and symptoms, pathophys- stiff neck, and fever. On physical assessment, you notice iology, and treatment of headaches vary based on the type of a petechial rash on his legs and torso. The physician di- headache experienced, these subjects are discussed separately agnoses meningococcal meningitis. for each type of headache. 1. What tests are likely to be performed? 2. What patient education should be planned for Migraine Headaches Mr. Chung? One long-held theory is that a migraine headache is caused 3. What infection control practices should be instituted? by cerebral vasoconstriction followed by vasodilation. The 4. What comfort measures might you offer to vasoconstriction can be due to a response triggered by the Mr. Chung? trigeminal nerve, which stimulates release of substance P, 5. What concerns do you have about how Mr. Chung a pain transmitter, into the v essels or by the release of contracted his illness? amines such as serotonin, norepinephrine, and epinephrine. Suggested answers are at the end of the chapter. A migraine may or may not begin with an aura (visual phe- nomena, such as a flashing light that precedes an attack). The tendency to de velop migraine headaches is often hereditary; they frequently begin in childhood or adoles- HEADACHES cence and are more common in w omen. Commonly used descriptors of migraine pain include throbbing, boring, As mentioned throughout this chapter, headache is a common vise-like, and pounding. The pain is usually on one side of symptom of neurologic disorders. However, most headaches the head. Noise and light tend to w orsen the headache, are transient events and do not indicate a serious pathological leading patients to seek a dark, quiet environment. Triggers 4068_Ch48_1118-1170 18/11/14 4:44 PM Page 1128 1128 UNIT THIRTEEN Understanding the Neurologic System for the headache include hormones (menses-related), The patient may state that the headache begins suddenly, changes in barometric pressure, specific foods, noise, bright typically at the same time of night. Throbbing and excruci- light, alcohol, and stress. ating are often the adjecti ves used by the patient. The There are two major types of migraine: migraine with headache tends to be unilateral, affecting the nose, eye, and aura and migraine without aura. There are four phases gener- forehead. A bloodshot, teary appearance of the affected eye ally associated with migraine headaches: prodromal, aura, is common. headache, and resolution. The preheadache phase (prodromal) Because of the brief nature of cluster headaches, treatment can include visual disturbances, difficulty speaking, and/or is difficult. A quiet, dark environment and cold compresses numbness or tingling. The headache that follo ws is often can lessen the intensity of the pain. NSAIDs or tric yclic accompanied by nausea and sometimes vomiting and can last antidepressants may be prescribed. for hours to days. Treatment of migraine may be prophylactic or directed Diagnosis of Headaches at an acute episode. Prophylactic treatment is usually re- Most headaches are diagnosed based on the patient’s history served for those patients experiencing one or more migraine and symptoms. MRI, CT, skull x-ray, arteriogram, EEG, cra- headaches per week. Dietary restrictions can be helpful if pre- nial nerve testing, and lumbar puncture to test CSF may be cipitating foods or beverages can be identified. done to rule out other causes for the headaches. Several types of medications are a vailable to treat acute migraine headaches. Nonsteroidal anti-inflammatory drugs Nursing Process for the (NSAIDs) such as naproxen (Naprosyn, Aleve) may be tried Patient With a Headache first. Ergot (Cafergot), a vasoconstrictor, is effective only if Data Collection taken before the v essel walls become edematous, usually The WHAT’S UP? mnemonic is particularly useful in help- within 30 to 60 minutes of headache onset. Triptans such as ing the patient pro vide useful information re garding the sumatriptan (Imitrex) and zolmitriptan (Zomig) w ork at the headache: serotonin receptor sites and ha ve a vasoconstricting action. Treximet combines naproxen and sumatriptan. Opioids are W—Where is the pain? Does it remain in one place or habit forming and are used only as a last resort. The poten- radiate to other areas of the head? Does the headache tially additive effects of multidrug regimens requires careful consistently start in one place? monitoring. H—How does the headache feel? Is it throbbing, steady, dull, bandlike, or does it have other Tension or Muscle Contraction Headaches qualities? Persistent contraction of the scalp and facial, cervical, and A—Aggravating or alleviating factors should be as- upper thoracic muscles can cause tension headaches. A sessed. Some aggravating factors include red wine, cycle of muscle tension, muscle tenderness, and further caffeine, chocolate, and foods containing nitrates or muscle tension is established. This cycle may or may not monosodium glutamate (MSG). Other factors in- be associated with v asodilation of cerebral arteries. clude particular stages of the menstrual cycle, emo- Headaches of this type can be associated with premenstrual tional stress, and tension. Alleviating factors might syndrome or psychosocial stressors such as anxiety , emo- include lying down in a dark room, cold compresses, tional distress, or depression. Symptoms typically develop or medications. gradually. Radiation of pain to the cro wn of the head and T—Timing can be a factor for a patient who experi- base of the skull, with variations in location and intensity, ences headaches just before or during her men- is common. Pressure, aching, steady, and tight are some of strual period. For other patients, there may be no the words patients use to describe the pain of tension predictive timing. Also ask how long the headache headaches. lasted. Care must be taken to thoroughly rule out physical causes S—Ask the patient to rate the severity on a scale of before attributing the headache to psychosocial origins. 0 to 10. Is the severity consistent or does it vary Symptom management may include the use of relaxation from headache to headache? techniques, massage of the affected muscles, rest, localized U—Ask about other useful data. For example, are heat application, nonopioid analgesics, and appropriate there associated symptoms, such as nausea, counseling. vomiting, or bloodshot eyes? P—Determine the patient’s perception of the headache. Cluster Headaches Does it interfere with the patient’s life? If so, how? Vascular disturbance, stress, anxiety, and emotional distress Has the patient had a previous evaluation of are all proposed causes of cluster headaches.As indicated by headaches? the name, these headaches tend to occur in clusters during a time span of several days to weeks. Months or even years can pass between episodes. Alcohol consumption may worsen the WORD BUILDING episodes. prodromal: pro—before + dromos—running 4068_Ch48_1118-1170 18/11/14 4:44 PM Page 1129 Chapter 48 Nursing Care of Patients With Central Nervous System Disorders 1129 Nursing Diagnoses, Planning, and Implementation Etiology Acute Pain (Headache) related to lack of knowledge of pain Epilepsy can be acquired or idiopathic (unkno wn cause). prevention and control techniques as evidenced by patient’s Causes of acquired epilepsy include traumatic brain injury pain rating and anoxic events. No cause has been identified for idiopathic EXPECTED OUTCOME: Headache will be prevented or con- epilepsy. The most common time for idiopathic epilepsy to trolled as evidenced by patient statement of no pain or begin is before age 20. New-onset seizures after this age are acceptable pain rating. most commonly caused by an underlying neurologic disorder. As the population ages, more older adults are ha ving first- Assist the patient to identify and reduce or eliminate ag- time seizure as a result of bleeding or bruising in the brain gravating factors. This can be accomplished by keeping a related to a fall. Multiple medications in the elder population headache diary for a time, recording the time of day the and untreated hypertension can increase the risk of f alls, as headache occurs, foods eaten or other aggravating factors, well as brain injury after a fall. description of the pain, identification of associated symp- toms such as nausea or visual disturbances, and other Signs and Symptoms factors related to headache symptoms. Identification of Symptoms of seizure activity correlate with the area of the triggers can help the patient lessen the frequency and brain where the seizure begins. Some patients experience an intensity of attacks. aura or sensation that warns that a seizure is about to occur. Encourage the patient to use alleviating techniques such An aura can be a visual distortion, a noxious odor, or an un- as biofeedback or stress reduction. This helps the patient usual sound. P atients who e xperience an aura may ha ve participate in the treatment of the headache and provides enough time to sit or lie do wn before the seizure starts, a sense of control over his or her illness. thereby minimizing the risk of injury. Teach the patient to use relaxation exercises and warm or cool moist compresses. These interventions may be help- PARTIAL SEIZURES. Repetitive, purposeless behaviors, called ful for tension headaches. automatisms, are the classic symptom of partial seizures.The Provide a dark room and rest to reduce stimulation during patient appears to be in a dreamlike state while picking at his a migraine headache. or her clothing, chewing, or smacking his or her lips. Patients Teach the patient about medications, appropriate dosage, may be labeled as mentally ill, particularly if automatisms in- expected action, side effects, and consequences of misuse. clude unacceptable social beha viors such as spitting or The patient will need to understand medication adminis- fondling themselves. Patients are not aware of their behavior tration for appropriate use at home. or that it is inappropriate. If the patient does not lose con- sciousness, the seizure is labeled as simple partial and usually Evaluation lasts less than 1 minute. Older terms for simple partial If interventions have been effective, the patient will under - seizures include Jacksonian and focal motor. If consciousness stand self-care to prevent and treat headaches and be able to is lost, it is called a comple x partial seizure or psychomotor report a reduction in headache pain and occurrences. seizure, and can last from 2 to 15 minutes. Partial seizures arising from the parietal lobe can cause paresthesias on the side of the body opposite the seizure SEIZURE DISORDERS focus. Visual disturbances are seen if the seizure originates in the occipital lobe. Involvement of the motor cortex results Seizures/Epilepsy in involuntary movements of the opposite side of the body. A seizure can be a symptom of epilepsy or of other neuro- Typically, movements begin in the arm and hand and can logic disorders such as a brain tumor or meningitis. Epilepsy spread to the leg and face. is a chronic neurologic disorder characterized by recurrent The postictal period is the recovery period after a seizure. seizure activity. Following a partial seizure, the postictal phase may be no more than a few minutes of disorientation. Pathophysiology GENERALIZED SEIZURES. Generalized seizures affect the en- The normal stability of the neuron cell membrane is tire brain. Two types of generalized seizures are absence impaired in indi viduals with epilepsy. This instability seizures and tonic-clonic seizures. Absence seizures, some- allows for abnormal electrical dischar ges to occur. These times referred to as petit mal seizures, occur most often in discharges cause the characteristic symptoms seen during children and are manifested by a period of staring that lasts a seizure. several seconds. Seizures can be classified as partial or generalized. Partial Tonic-clonic seizures are what most people envision when seizures begin on one side of the cerebral corte x. In some they think of seizures; they are sometimes called grand mal cases, the electrical dischar ge spreads to the other hemi- sphere and the seizure becomes generalized. Generalized seizures are characterized by in volvement of both cerebral WORD BUILDING hemispheres. postictal: post—after + ictal—seizure 4068_Ch48_1118-1170 18/11/14 4:44 PM Page 1130 1130 UNIT THIRTEEN Understanding the Neurologic System seizures or convulsions. Tonic-clonic seizures follow a typical Therapeutic Measures progression. Aura and loss of consciousness may or may not occur. The tonic phase, lasting 30 to 60 seconds, is charac - If an underlying cause for the seizure is identified, treatment terized by rigidity, causing the patient to f all if not lying focuses on correcting the cause. If no cause is found or if the down. The pupils are f ixed and dilated, the hands and ja ws seizures continue despite treatment of concurrent disorders, are clenched, and the patient can temporarily stop breathing. treatment focuses on stopping or pre venting the seizure The clonic phase is signaled by contraction and relaxation of activity. all muscles in a jerky, rhythmic fashion. The extremities can Numerous anticonvulsant medications are available, each move forcefully, causing injury if the patient strikes furniture with specific actions, therapeutic ranges, and potential side or walls. The patient is often incontinent. Biting the lips or effects (Table 48.5). Typically, the patient is started on one tongue can cause bleeding. drug, and the dosage is increased until therapeutic levels are The postictal period is usually longer after a tonic-clonic attained or side effects become troublesome. If seizures are seizure. Patients may sleep deeply for 30 minutes to se veral not controlled on a single drug, another medication is added. hours. Following this deep sleep, patients may report Many anticonvulsants require periodic blood tests to monitor headache, confusion, and f atigue. Patients may realize that serum levels as well as kidne y and liver functions. Most of they had a seizure but not remember the event itself. these medications can cause drowsiness, so teach the patient to avoid driving or operating machinery until the ef fects of Diagnostic Tests the drug are kno wn. Driving is also contraindicated until An EEG is the most useful test for e valuating seizures. An seizures are under control. EEG can determine where in the brain the seizures start, the If a patient must discontinue an anticon vulsant, it should frequency and duration of seizures, and the presence of sub- be tapered slowly according to manufacturer directions. Stop- clinical (asymptomatic) seizures. Sleep deprivation and flash- ping an anticonvulsant abruptly can result in status epilepticus, ing light stimulation may be used to e valuate the seizure discussed later. If seizures continue despite anticon vulsant threshold. See Chapter 47 for more information on EEGs. therapy, surgical intervention may be considered. TABLE 48.5 ANTICONVULSANT MEDICATIONS Medication Class/Action Examples Nursing Implications Suppress abnormal discharge carbamazepine (Tegretol) Monitor CBC. of neurons, suppress spread Therapeutic level 6–12 mcg/mL. of seizure activity from focus Do not crush SR form. to other parts of brain. ezogabine (Potiga) Monitor for urinary retention. gabapentin (Neurontin) Blood levels not necessary lacosamide (Vimpat) Injectable form available. May increase risk of suicidal ideation. levetiracetam (Keppra) May need reduced dose for older adults. Assess WBC, RBC, and liver function tests. lamotrigine (Lamictal) Discontinue therapy and notify health care practi- tioner if rash appears. Monitor blood levels. topiramate (Topamax) Blood levels not necessary. phenytoin (Dilantin) Regular dental care essential Therapeutic level is 10–20 mcg/mL. Binds to tube feedings—hold tube feeding 1 hr before and 2 hr after dose. phenobarbital (Luminal) Monitor vital signs. valproic acid (Depakote) Therapeutic level 15–40 mcg/mL. Therapeutic level 50–100 mcg/mL. Do not crush SR form. Emergency Agents Potentiate GABA, an inhibitory lorazepam (Ativan) Given to stop a seizure that has not resolved neurotransmitter in the CNS. diazepam (Valium, Diastat) within 5 minutes. Given IM or IV push by emergency personnel. Rectal Diastat may be given at home. Note. RBC = red blood cell; SR = sustained release; WBC = white blood cell. 4068_Ch48_1118-1170 18/11/14 4:44 PM Page 1131 Chapter 48 Nursing Care of Patients With Central Nervous System Disorders 1131 Surgical Management Status Epilepticus The success of surgical intervention for epilepsy depends on Status epilepticus is characterized by at least 30 minutes of identification of an epileptic focus within nonvital brain tis- repetitive seizure activity without a return to consciousness. sue. The surgeon attempts to resect the area af fected to pre- This is a medical emergency and requires prompt intervention vent spread of seizure activity. In some cases, seizures can be to prevent irreversible neurologic damage. Abrupt cessation of cured, but in others, the goal is to reduce the frequenc y or anticonvulsant therapy is the usual cause of status epilepticus. severity of the seizures. If no focus is identified or if it is in a Seizure activity precipitates a significant increase in the vital area such as the motor cortex or speech center, surgery brain’s need for glucose and oxygen. This metabolic demand is not feasible. is even greater during status epilepticus. Irre versible neu- The preoperative assessment for epilepsy sur gery is an ronal damage can occur if cerebral metabolic needs cannot extensive multistage process. Thorough assessment and be fulfilled. Adequate oxygenation must be maintained, if teaching are essential. To adequately identify seizure foci, the necessary, by intubating and mechanically v entilating the patient is weaned off anticonvulsant therapy. Increasing the patient. These patients are also at significant risk for aspira- frequency of seizures with weaning is anxiety provoking for tion. Therefore, it is important that the nurse assist in airway patients and significant others. maintenance and suction as needed to pre vent hypoxia and aspiration pneumonia. Emergency Care Intravenous (IV) diazepam (Valium) or lorazepam (Ativan) Emergency care is required when a seizure occurs. The is given to stop active seizures. Diazepam can also be gi ven prime objective is to prevent injury during a seizure. Side rectally. Because both of these drugs can cause respiratory rails, if used, should be padded to pre vent injury if the depression, careful airw ay management is required. After patient strikes his or her e xtremities against them. If the obtaining serum drug levels, anticonvulsant therapy is adjusted patient falls to the floor , move furniture out of the w ay. to achieve therapeutic levels. Maintain a patent airway and, if possible, turn the patient If seizures remain resistant to treatment, a barbiturate on his or her side to prevent aspiration if vomiting occurs. coma may be induced with IV pentobarbital. The last line of Do not force an airw ay or anything else into the patient’s treatment for status epilepticus is general anesthesia or phar- mouth once the seizure has be gun. Do not restrain the macological paralysis. Both of these therapies require intu- individual because this can also increase the risk of injury. bation, mechanical ventilation, and management in an ICU Observe and document the patient’ s behavior during the setting. Continuous EEG monitoring is used to verify that the seizure: which part of the body was first involved, progres- seizures have actually stopped. A patient treated with neuro- sion of the seizure, and the length of time the seizure lasted muscular blockade drugs can still be seizing b ut have no (see “Patient Perspective”). After the seizure, assess the visible manifestations. patient for breathing, suction if necessary , and, in rare For more information on seizures, visit the Epilepsy cases, initiate rescue breathing or cardiopulmonary resus- Foundation of America at www.efa.org. citation (CPR) as indicated. Psychosocial Effects Finances can be a major concern to patients with seizure disorders. Some patients with epilepsy e xperience hiring discrimination, or they may not qualify for some jobs in Patient Perspective which safety is a concern. Remind patients that f alsifying information on job applications may be grounds for dis- Mrs. Rowley missal. Refusal of health insurance co verage can create I have had seizures for 35 years and, as a result of financial hardships for patients on long-term medications. falling during seizures, have experienced cuts, bruises, Most patients whose seizures are controlled can w ork and and a broken bone. I usually have an aura that lets me lead productive lives. A social w orker can help e xplore know a seizure is about to occur. This is helpful if I can options for financial assistance if needed. get myself to a safe place to prevent falling or being Patients with poorly controlled seizures should not operate injured. When a patient is having a seizure you can motor vehicles. In today’s society, a driver’s license is a sign best help by using padding such as pillows or blankets of adulthood and independence, and patients who cannot for protection, talking calmly, and using gentle touch drive can experience lowered self-esteem. Job opportunities to prevent injury. You should not sit on or hold down may be limited for patients who depend on public transporta- someone during a seizure. I have had the frightening tion. Encourage the patient to obtain a state identif ication experience of waking up with a nurse sitting on me and card. This can be used in place of a driver’s license for iden- holding down my arms. After you have protected the tification. patient, let the person come out of the seizure naturally. Patients may limit interpersonal relationships out of fear When the seizure is over, I usually want to sleep of having a seizure. The involuntary movements, sounds, because seizures are exhausting. and possible incontinence that occur with seizures are em- barrassing to patients and can be frightening to laypeople. 4068_Ch48_1118-1170 18/11/14 4:44 PM Page 1132 1132 UNIT THIRTEEN Understanding the Neurologic System Role-playing may help the patient determine when and how verbalization of understanding of needed lifestyle changes is to confide in others. another indication of success. Patients should be able to state measures to pre vent injury if a seizure should occur and Nursing Process for the Patient With Seizures should verbalize understanding of all medications and their Data Collection administration schedules. Therapeutic drug le vels can be Perform a general neurologic examination of the patient with measured to evaluate adherence to the medication regimen. a history of seizures. Determine the type of seizure manifes- tations and type of aura if any. Assess the patient’s knowledge TRAUMATIC BRAIN INJURY of the disease and its treatment. It is important to assess whether the patient has the resources to purchase prescribed Traumatic brain injury is a major cause of death and disability anticonvulsant medications and whether the medication reg- in adults. Young men make up a lar ge proportion of brain imen is adhered to. Drug levels can help determine degree of injury victims. adherence to therapy. Pathophysiology Nursing Diagnoses, Planning, and Implementation Traumatic brain injury is a complex phenomenon with results Risk for Injury related to seizure activity ranging from no detectable ef fect to a persistent v egetative EXPECTED OUTCOME: The patient will remain free from state. Trauma can result in hemorrhage, contusion or lacera- injury. tion of the brain, and damage at the cellular level. In addition Instruct the patient with generalized seizures to recognize to the primary insult, the brain injury can be compounded by an aura and to get to safety if it occurs. This may mean cerebral edema, hyperemia, or hydrocephalus. lying down away from furniture or other objects. This Etiology helps prevent injury during involuntary movements. Institute seizure precautions for the patient admitted to a Motor vehicle accidents account for the largest percentage of health care institution. See Table 48.6 for precautions and traumatic brain injuries. F alls, sports-related injuries, and interventions to prevent injury. violence are also common causes of traumatic brain injury. Encourage all patients to wear medical alert jewelry or The brain is susceptible to various types of injury that can other identification to alert others to the presence of be classified in several ways. The term closed head injury or seizure disorder. nonpenetrating injury is used when there has been rapid back Assist patients to identify conditions that trigger seizures. and forth movement of the brain that causes bruising and tear- Hypoglycemia, hypoxia, and hyponatremia are all poten- ing of brain tissues and v essels, but the skull is intact. An tial triggers of hypersensitive neurons. Teach the patient open head injury or penetrating injury refers to a break in the the importance of a consistent schedule of eating and skull. Acceleration injury is the term used to describe a mov- sleeping. The patient may be able to prevent seizures ing object hitting a stationary head. An example of this type by avoidance of triggers. Risk for Ineffective Self Health Management related to complex regimen and possible lack of resources EXPECTED OUTCOME: The patient will follow medication reg- TABLE 48.6 INTERVENTIONS FOR imen as evidenced by therapeutic drug levels and controlled SEIZURES seizure activity. Seizure Precautions Assess patient’s ability to obtain and pay for medication. Pad side rails of hospital bed with commercial pads Stopping a medication suddenly can result in status or bath blankets folded over and pinned in place. epilepticus. Keep call light within reach. Refer patient to a case manager or social worker, if needed, Assist patient when ambulating. to assist with obtaining resources for medications. Keep suction and oral airway at bedside. Teach the patient about medication action, dose, side effects, schedule, and the importance of not stopping Nursing Care During a Seizure treatment suddenly. Patients with seizures can have sev- Stay with patient. eral medications to take several times each day. Patients Do not restrain patient. who understand their regimens are more likely to comply. Protect from injury (move nearby objects). Teach the patient about the importance of regular blood Loosen tight clothing. tests if required. Therapeutic blood levels help prevent Turn to side when able to prevent occlusion of airway seizures (too low) and toxicity (too high). or aspiration. Suction if needed. Evaluation Monitor vital signs when able. Successful care of a patient with epilepsy is manifested by a Be prepared to assist with breathing if necessary. decrease in seizures to the lowest possible frequency. Patient 4068_Ch48_1118-1170 18/11/14 4:44 PM Page 1133 Chapter 48 Nursing Care of Patients With Central Nervous System Disorders 1133 of injury is a patient who is hit in the head with a baseball subdural hematoma increases in size, the patient may exhibit bat. A deceleration injury occurs when the head is in motion one-sided paralysis of e xtraocular movement, extremity and strikes a stationary surface. This type of injury is seen in weakness, or dilation of the pupil. Le vel of consciousness patients who trip and f all, hitting their head on furniture or can deteriorate further as ICP increases. the floor. Older adults and people with alcoholism are particularly A combination of acceleration-deceleration injury occurs prone to chronic subdural hematomas. Atrophy of the brain, when the stationary head is hit by a mobile object and the common in these populations, stretches the veins between the head then strikes a stationary surf ace. A soccer player who brain and the dura. A seemingly minor fall or blow to the head sustains a blow to the head and then hits the ground with his can cause these stretched v eins to rupture and bleed. Often or her head can sustain an acceleration-deceleration injury. there are no other injuries associated with the trauma. Rotational injuries have the potential to cause shearing Because a chronic subdural hematoma can develop weeks to damage to the brain, as well as lacerations and contusions. months after the injury , the patient may not remember an Rotational injuries can be caused by a direct blow to the head injury occurring. or can occur during a motor vehicle accident in which the ve- The patient with a chronic subdural hematoma may be for- hicle is struck from the side. Twisting of the brainstem can getful, lethargic, or irritable or may report a headache. If the damage the reticular activating system, causing loss of con- hematoma persists or increases in size, the patient can develop sciousness. Movement of the brain within the skull can result hemiparesis and pupillary changes. The patient or significant in bruising or tearing of brain tissue where it comes in contact other may not associate the symptoms with a previous injury with the inside of the skull. and therefore may delay seeking medical care. Types of Brain Injury and EPIDURAL HEMATOMA. About 10% of patients with se vere Signs and Symptoms brain injuries develop epidural hematomas. This collection of blood between the dura mater and skull is usually arterial in na- Concussion ture and is often associated with skull fracture (see Fig. 48.5). Cerebral concussion is considered a mild brain injury. If there Arterial bleeding can cause the hematoma to become lar ge is a loss of consciousness, it is for 5 minutes or less. Concus- very quickly. Patients with epidural hematoma typically sion is characterized by headache, dizziness, or nausea and exhibit a progressive course of symptoms. The patient loses vomiting. The patient may describe amnesia of events before consciousness directly after the injury; he or she then regains or after the trauma. On clinical examination, there is no skull consciousness and is coherent for a brief period. The patient or dura injury and no abnormality detected on CT or MRI. then develops a dilated pupil and paralyzed e xtraocular muscles on the side of the hematoma and becomes less Contusion responsive. If there is no interv ention, the patient becomes Cerebral contusion is characterized by bruising of brain unresponsive. Seizures or hemiparesis can occur. Once the tissue, possibly accompanied by hemorrhage. There can be multiple areas of contusion, depending on the causati ve mechanism. Severe contusions can result in dif fuse axonal injury. The symptoms of a cerebral contusion depend on the area of the brain involved. Brainstem contusions af fect level of consciousness. Decreased level of consciousness can be transient or perma- Dura mater nent. Respirations, pupil reaction, eye movement, and motor response to stimuli can also be affected. The autonomic nerv- ous system can be af fected by edema or by hypothalamic injury, causing rapid heart rate and respiratory rate, fever, and A diaphoresis. Hematoma SUBDURAL HEMATOMA. Subdural hematomas are classified as acute or chronic based on the time interval between injury Dura mater and onset of symptoms. Acute subdural hematoma is char- acterized by appearance of symptoms within 24 hours fol- lowing injury. The bleeding is typically venous in nature and accumulates between the dura and arachnoid membranes (Fig. 48.5). About 24% of patients who sustain a severe brain