NCM 118 - Neurological Disorders and Trauma - Emergency Care PDF

NCM 118 – CARE OF CLIENTS WITH PROBLEMS WITH LIFE THREATENING CONDITIONS, ACUTELY ILL/MULTI-ORGAN PROBLEM, HIGH ACUITY & EMERGENCY MODULE 2: NEUROLOGICAL DISORDERS AND TRAUMA LESSON 1: INCREASED INTRACRANIA...

NCM 118 – CARE OF CLIENTS WITH PROBLEMS WITH LIFE THREATENING CONDITIONS, ACUTELY ILL/MULTI-ORGAN PROBLEM, HIGH ACUITY & EMERGENCY MODULE 2: NEUROLOGICAL DISORDERS AND TRAUMA LESSON 1: INCREASED INTRACRANIAL PRESSURE HERNIATION ○ Results from an excessive increase in ICP Increased ICP affects many patients with acute when the pressure builds up and the brain neurologic conditions because pathologic tissue presses down on the brain stem conditions alter the relationship between CEREBRAL RESPONSE TO INCREASED ICP intracranial volume and ICP. ○ Steady perfusion up to 40 mmHg Although ele-vated ICP is most commonly ○ Cushing's Response associated with head injury, it also may be seen as Vasomotor center triggers rise in BP a secondary effect in other conditions, such as to increase ICP brain tumors, subarachnoid hemorrhage, and toxic Sympathetic response is increased and viral encephalopathies. BP but the heart rate is SLOW COMMON CAUSES Respiration becomes SLOW ○ Head injury CLINICAL MANIFESTATIONS ○ Stroke ○ Changes in the LOC – usually THE ○ Inflammatory lesions EARLIEST ○ Brain tumor ○ Pupillary changes – fixed, slowed ○ Surgical complications response PATHOPHYSIOLOGY ○ Headache ○ The cranium only contains the brain ○ Vomiting substance, the CSF and the blood/blood ○ LATE MANIFESTATIONS vessels Cushing's Triad ○ MONRO-KELLIE hypothesis- an increase in ↳ Systolic hypertension any one of the components causes a ↳ Bradycardia change in the volume of the other ↳ Wide pulse pressure ○ Any increase or alteration in these Bradypnea structures will cause increased ICP Hyperthermia ○ Increased ICP may reduce cerebral blood Abnormal posturing flow, resulting in ischemia and cell death. NURSING INTERVENTIONS ○ Early stages of cerebral ischemia, the ○ Elevate the head of the bed 30 degrees – vasomotor centers are stimulated and the to promote venous drainage systemic pressure rises to maintain ○ Maintain a patent airway (assists in cerebral blood flow. administering 100% oxygen or controlled ○ Slow bounding pulse and respiratory hyperventilation) irregularities and changes in BP will be the ○ Administer prescribed medications common signs of ICP. Mannitol – to produce negative ○ Concentration of carbon dioxide in the fluid balance blood and in the brain tissue also plays a Corticosteroid – to reduce edema role in the regulation of cerebral blood Anticonvulsants – to prevent flow. seizures ○ Cerebral Vasodilation is due to increase of ○ Reduce environmental stimuli PaCO2 which leads to increase of cerebral ○ Avoid activities that can increase ICP like blood flow and ICP. valsalva, coughing, shivering, and vigorous CEREBRAL EDEMA suctioning, and flexion of the head. ○ Abnormal accumulation of fluid in the ○ Keep head on a neutral position. intracellular space, extracellular space or Avoid extreme flexion and valsalva both. ○ Monitor for secondary complications. ○ Several mechanisms attempt to Diabetes Insipidus compensate for the increasing ICP. SIADH ○ These compensatory mechanisms include autoregulation, as well as decreased production and flow of CSF. 1 NCM 118 – CARE OF CLIENTS WITH PROBLEMS WITH LIFE THREATENING CONDITIONS, ACUTELY ILL/MULTI-ORGAN PROBLEM, HIGH ACUITY & EMERGENCY Increased intracranial pressure (ICP) is a rise in pressure around your brain. ○ It may be due to an increase in the amount of fluid surrounding your brain. ○ For example, there may be an increased amount of the cerebrospinal fluid that naturally cushions your brain or an increase in blood in the brain due to an injury or a ruptured tumor. Increased ICP can also mean that your brain tissue itself is swelling, either from injury or from an illness such as epilepsy. ○ Increased ICP can be the result of a brain injury, and it can also cause a brain injury. The rigid cranial vault contains brain tissue (1400 g), blood (75 mL), and CSF (75 mL). ○ The volume and pressure of these three components are usually in a state of equilibrium and produce the ICP. LESSON 2: TRAUMATIC BRAIN INJURY ○ ICP is usually measured in the lateral ventricles, with the normal pressure Traumatic Brain Injury (TBI) is a disruption in the being 0 to 10 mmHg, and 15 mmHg being normal function of the brain that can be caused by the upper limit of normal. a blow, bump or jolt to the head, the head The Monro-Kellie hypothesis states that, because suddenly and violently hitting an object or when an of the limited space for expansion within the skull, object pierces the skull and enters brain tissue an increase in any one of the components causes TYPES OF BRAIN INJURY a change in the volume of the others. ○ CONCUSSION ○ Because brain tissue has limited space to It is a temporary loss of neurologic expand, compensation typically is function with no apparent accomplished by displacing or shifting CSF, structural damage. increasing the absorption or diminishing ↳ May or may not produce the production of CSF, or decreasing a brief loss of cerebral blood volume. consciousness If brain tissue in the frontal lobe is affected, the patient may exhibit bizarre irrational behavior, whereas involvement of the temporal lobe can produce temporary amnesia or disorientation. Mild concussion – may lead to a period of observed or self- reported transient confusion, disorientation, or impaired consciousness Classic concussion – is an injury that results in a loss of consciousness; characteristically, this usually lasts less than 6 hours. 2 NCM 118 – CARE OF CLIENTS WITH PROBLEMS WITH LIFE THREATENING CONDITIONS, ACUTELY ILL/MULTI-ORGAN PROBLEM, HIGH ACUITY & EMERGENCY ○ CONTUSION TYPES OF HEMATOMAS A moderate to severe head injury, ○ Epidural Hematoma the brain is bruised and damaged in Blood collects in the epidural a specific area because of severe (extradural) space between the acceleration-deceleration force or skull and the dura mater. Symptoms blunt trauma. are caused by the expanding Characterized by loss of hematoma. consciousness associated with Epidural hematomas are often stupor and confusion. characterized by a brief loss of It can include tissue alteration and consciousness followed by a lucid neurologic deficit without interval in which the patient is hematoma formation, alteration in awake and conversant. consciousness without localizing ○ Subdural Hematoma signs, and hemorrhage into the Is a collection of blood between the tissue that varies in size and is dura and the brain, a space surrounded by edema. normally occupied by a thin ○ DIFFUSE AXONAL INJURY (DAI) cushion of fluid. It is a result from widespread The most common cause of shearing and rotational forces that subdural hematoma is trauma, but produce damage throughout the it can also occur as a result of brain to axons in the cerebral coagulopathies or rupture of an hemispheres, corpus callosum, and aneurysm. brain stem. Acute and Subacute Subdural Associated with prolonged Hematoma – associated with major traumatic coma; it is more serious head injury involving contusion or and is associated with a poorer laceration. prognosis than a focal lesion or ↳ Clinical symptoms ischemia develop over 24 to 48 ○ INTRACRANIAL HEMORRHAGE hours. Hematomas are collections of Chronic Subdural Hematoma – It blood in the brain that may be can develop from seemingly minor epidural (above the dura), subdural head injuries and are seen most (below the dura), or intracerebral frequently in the elderly. (within the brain) ↳ It can resemble other Major symptoms are frequently conditions; like , it may delayed until the hematoma is large be mistaken for a stroke. enough to cause distortion of the ○ Intracerebral Hemorrhage and brain and increased ICP. Hematoma The signs and symptoms of cerebral Bleeding into the substance of the ischemia resulting from brain. compression by a hematoma are It is commonly seen in head injuries variable and depend on the speed when force is exerted to the head with which vital areas are affected over a small area. and the area that is injured 3 NCM 118 – CARE OF CLIENTS WITH PROBLEMS WITH LIFE THREATENING CONDITIONS, ACUTELY ILL/MULTI-ORGAN PROBLEM, HIGH ACUITY & EMERGENCY These hemorrhages within the brain may also result from the ○ Complex Injury following: Blood or fluid escaping from nose ↳ Systemic hypertension, or ears which causes Pupils becoming unequal in sPe degeneration and Blurred vision rupture of a vessel DIAGNOSTIC TESTS AND ASSESSMENT ↳ Rupture of a saccular ○ Plain x-rays of the skull are recommended aneurysm as a way to evaluate patients with only ↳ Vascular anomalies mild neurological dysfunction. ↳ Intracranial tumors ○ Computed tomography scan (CT or CAT ↳ Bleeding disorders such scan) is the gold standard for the as leukemia, radiological assessment of a TBI patient. It hemophilia, aplastic is an excellent test for detecting the anemia, and presence of blood and fractures, the most thrombocytopenia crucial lesions to identify in medical ↳ Complications of trauma cases anticoagulant therapy ○ Magnetic resonance imaging (MRI) CLINICAL MANIFESTATIONS demonstrate the existence of lesions that ○ Vomiting, Lethargy, Headache, Confusion were not detected on the CT scan ○ Altered level of consciousness, Seizures ○ Positron emission tomography (PET) is ○ Vision changes (blurred vision or seeing available in some trauma centers for double, unable to tolerate bright light, assessing brain function. loss of eye movement, blindness) ○ Assessment also includes determining the ○ Pupillary abnormalities (changes in shape, patient’s LOC using the Glasgow Coma size, and response to light) Scale (GCS) and assessing the patient’s ○ Absent corneal reflex and or Gag reflex response to tactile stimuli, pupillary ○ Cerebrospinal fluid (CSF) (clear or response to light, corneal and gag blood-tinged) appear from the ears or reflexes, and motor function. nose NURSING MANAGEMENT ○ Dizziness and balance concerns ○ Monitoring Neurologic Function ○ Changes in vital signs (altered respiratory Level of Consciousness – The GCS is pattern, widened pulse pressure, used to assess LOC at regular bradycardia, tachycardia, hypothermia, or intervals, because changes in the hyperthermia) LOC pre- cede all other changes in ○ Tinnitus - Ringing in the ears or changes in vital and neurologic signs. hearing Vital Signs – Although a change in ○ Cognitive difficulties, Sensory Dysfunction LOC is the most sensitive ○ Inappropriate emotional responses neurologic indication of ○ Speech difficulties (slurred speech, deterioration of the patient’s inability to understand and/or articulate condition, vital signs also are words) monitored at frequent intervals to ○ Droopy eyelid or facial weakness assess the intracranial status. ○ Sudden onset of neurologic deficits Motor Function – Motor function is HEAD INJURY SIGNS AND SYMPTOMS assessed frequently by observing ○ Moderate Injury spontaneous movements, asking Headache the patient to raise and lower the Loss of memory face (amnesia) extremities, and comparing the Confusion strength and equality of the upper Altered response to commands and and lower extremities at periodic touch intervals. Wounds to the scalp or face Nausea Vomiting Dizziness 4 NCM 118 – CARE OF CLIENTS WITH PROBLEMS WITH LIFE THREATENING CONDITIONS, ACUTELY ILL/MULTI-ORGAN PROBLEM, HIGH ACUITY & EMERGENCY ○ Maintaining patient airway. – One of the ○ Maintaining Skin Integrity most important nursing goals in the Patients with TBI often require management of head injury is to establish assistance in turning and and maintain an adequate airway. positioning because of immobility Maintaining the unconscious or unconsciousness. Prolonged patient in a position that facilitates pressure on the tissues decreases drainage of oral secretions, with circulation and leads to tissue the head of the bed elevated about necrosis. 30 degrees to decrease intracranial SPECIFIC NURSING MEASURES INCLUDE THE venous pressure FOLLOWING Establishing effective suctioning ○ Assessing all body surfaces and procedures (pulmonary secretions documenting skin integrity every 8 hours produce coughing and straining, ○ Turning and repositioning the patient which increase ICP) every 2 hours Guarding against aspiration and ○ Providing skin care every 4 hours respiratory insufficiency ○ Assisting the patient to get out of bed to a Closely monitoring arterial blood chair three times a day gas values to assess the adequacy MEDICAL MANAGEMENT of ventilation. The goal is to keep ○ Surgery is required for evacuation of blood gas values within the normal blood clots, débridement and elevation of range to ensure adequate cerebral depressed fractures of the skull, and blood flow. suture of severe scalp lacerations. Monitoring the patient who is ○ ICP is monitored closely; if increased, it is receiving mechanical ventilation for managed by maintaining ad- equate pulmonary complications such as oxygenation, elevating the head of the acute respiratory distress syndrome bed, and maintaining normal blood (ARDS) and pneumonia volume. ○ Monitoring Fluids and Electrolytes ○ Comatose patients are intubated and Balance mechanically ventilated to ensure Brain damage can produce adequate oxygenation and protect the metabolic and hormonal airway. dysfunctions. ○ Anti Seizure drug and Osmotic Diuretics The monitoring of serum may be administered electrolyte levels is important, ○ A nasogastric tube may be inserted, especially in patients receiving because reduced gastric motility and osmotic diuretics, those with reverse peristalsis are associated with syndrome of inappropriate head injury, making regurgitation and antidiuretic hormone (SIADH) aspiration common in the first few hours. secretion, and those with posttraumatic diabetes insipidus. LESSON 3: STROKE – CEREBROVASCULAR ACCIDENT (CVA) ○ Promoting Adequate Nutrition Early initiation of nutritional therapy has been shown to improve outcomes in patients with head injury. Parenteral nutrition via a central line or enteral feedings administered via a nasogastric or nasojejunal feeding tube should be considered 5 NCM 118 – CARE OF CLIENTS WITH PROBLEMS WITH LIFE THREATENING CONDITIONS, ACUTELY ILL/MULTI-ORGAN PROBLEM, HIGH ACUITY & EMERGENCY TIME IS CRITICAL! ○ Cryptogenic Stroke – in most cases, a Recognizing symptoms and acting fast to get stroke is caused by a blood clot that medical attention can save lives and limit blocks the flow of blood to the brain. disabilities. In some instances, despite testing, The longer the time period that the person the cause of a stroke cannot be remains unresponsive, the less likely it is that the determined. person will recover. A stroke of unknown cause is called The first few days after onset is critical. a “ cryptogenic stroke.” The goal of acute stroke care is the revival and ○ Brain Stem Stroke – When stroke occurs rescue of the ischemic penumbra by rapid in the brain stem, it can affect both sides restoration of blood flow of the body and may leave someone in a BRAIN METABOLISM ‘locked-in’ state. ○ The brain’s sole source of energy is When a locked-in state occurs, the aerobic or oxidative metabolism. patient is generally unable to speak ○ Therefore, the brain requires a constant or move below the neck. supply of O2 and glucose, 24 hours a day ISCHEMIC STROKE for 365 days. (24/7/365) ○ Thrombotic Strokes – caused by a blood STROKE/CVA clot that develops in the blood vessels ○ The biology of stroke is such that each inside the brain. moment of ischemia and tissue injury ○ Embolic Strokes – caused by blood clots increases the degree of irreversible tissue or plaque debris that develops elsewhere damage. in the body and then travels to one of the ○ Also called a “Brain Attack” blood vessels in the brain via the ○ A stroke occurs when blood flow to the bloodstream. brain is interrupted by a blocked or burst ○ ATHEROSCLEROSIS blood vessel hardening of the arteries ○ When brain tissue is deprived of blood “athero” – gruel or paste flow, neurons die within minutes. “sclerosis” – hardness Surrounding a core of infarction is It’s the process in which deposits of an “ischemic penumbra” poorly fatty substances, cholesterol, perfused but viable tissue at risk for cellular waste products, calcium, imminent infarction. and other substances build up in ○ This cuts off the supply of oxygen and the inner lining of an artery. nutrients, causing damage to the brain This buildup is called plaque. tissue HEMORRHAGIC STROKE TYPES OF STROKE ○ About 15% of all strokes but responsible ○ Ischemic Stroke (Clots) – occurs when a for 30% of stroke deaths blood vessel supplying blood to the brain ○ Results from a weakened vessel that is obstructed. It accounts for 87 percent of ruptures and bleeds into the surrounding all strokes. brain. ○ Hemorrhagic Stroke (Bleeds) – occurs ○ The blood accumulates and compresses when a weakened blood vessel ruptures. the surrounding brain tissue. Aneurysms ○ caused commonly by hypertensive Arteriovenous malformations bleeding (AVMs) ○ TIA (Transient Ischemic Attack) – called a “mini-stroke,” It’s caused by a serious temporary clot. This is a warning stroke and should be taken seriously. 6 NCM 118 – CARE OF CLIENTS WITH PROBLEMS WITH LIFE THREATENING CONDITIONS, ACUTELY ILL/MULTI-ORGAN PROBLEM, HIGH ACUITY & EMERGENCY THE STROKE CONTINUUM COMMON STROKE SYMPTOMS ○ TIA – temporary neurologic loss of less ○ Weakness or paralysis than 24 hours duration ○ Numbness, tingling, decreased sensation Acute onset of neurological ○ Vision changes dysfunction, due to focal brain ○ Speech problems ischemia, which completely ○ Swallowing difficulties or drooling resolves within 60 minutes ○ Loss of memory ↳ sudden and short-lived ○ Vertigo (spinning sensation) attack ○ Loss of balance and coordination ↳ is a "mini-stroke" that ○ Personality changes occurs when a blood ○ Mood changes (depression, apathy) clot blocks an artery for ○ Drowsiness, lethargy, or loss of a short time. consciousness ○ Reversible Neurologic deficits (RIND) – ○ Uncontrollable eye movements or eyelid similar to TIA, but symptoms can last up drooping to a week ISCHEMIC STROKE ○ Stroke in Evolution (SIE) – gradual ○ There is disruption of the cerebral blood worsening of symptoms of brain ischemia flow due to obstruction by embolus or ○ Completed Stroke (CS) - symptoms of thrombus stroke stable over a period and ○ CLINICAL MANIFESTATIONS rehabilitation can begin Numbness or weakness PATHOPHYSIOLOGY OF ISCHEMIC STROKE Confusion or change of LOC ○ Disruption of blood supply Motor and speech difficulties ○ Anaerobic metabolism ensues Visual disturbance ○ Decreased ATP production leads to Severe headache impaired membrane function ○ MOTOR LOSS ○ Cellular injury and death can occur Hemiparesis – mild loss of strength in a leg, arm, or face.; It can also be paralysis on one side of the body. Hemiplegia – severe or complete loss of strength or paralysis on one side of the body. ○ COMMUNICATION LOSS Dysarthria – difficulty in speaking Aphasia – loss of speech Apraxia – inability to perform a previously learned action ○ PERCEPTUAL DISTURBANCES Hemianopsia – loss of vision in half of the visual field of one or both RISK FACTORS eyes.; Common causes are stroke, ○ NON-MODIFIABLE brain tumor, and trauma to the Advanced age brain. Gender ○ SENSORY LOSS Race Paresthesia – pins and needles Family history sensation ○ MODIFIABLE ○ IN EMBOLISM Hypertension Usually occurs without warning Cardio disease Client often with history of Diabetes mellitus cardiovascular disease Hypercholesterolemia ○ IN THROMBOSIS Obesity Dizzy spells or sudden memory loss Smoking No pain, and the client may ignore Alcoholism symptoms 7 NCM 118 – CARE OF CLIENTS WITH PROBLEMS WITH LIFE THREATENING CONDITIONS, ACUTELY ILL/MULTI-ORGAN PROBLEM, HIGH ACUITY & EMERGENCY ○ IN CEREBRAL HEMORRHAGE DIAGNOSTIC TEST May have warnings like dizziness ○ CT Scan (Computed Tomography) and ringing in the ears (tinnitus) Images provide cross-sectional Violent headache, with nausea and views of the brain, with vomiting distinguishing differences in tissue ○ SUDDEN ONSET CVA densities of the skull, cortex, Usually most severe subcortical structures, and Loss of consciousness ventricles Face becomes red Abnormalities of tissues indicate Breathing is noisy and strained possible tumor masses, brain Pulse is slow but full and bounding infarction, displacement of the Elevated BP ventricles, and cortical atrophy. May be in a deep coma With radiation risk CAROTID ARTERY If contrast medium will be used ○ Middle cerebral artery ↳ Ensure consent, assess Aphasia – communication disorder for allergies to dyes and that occurs due to brain damage in iodine or seafood, one or more areas that control flushing and metallic language. (verbal communication, taste are expected as written communication, or both). the dye is injected Dysphagia – inability to swallow ○ MRI (Magnetic Resonance Imaging) foods or liquids with ease. Obtain images of the different Hemiparesis on the OPPOSITE side areas of the body. – more severe on the face and arm Potential for identifying a cerebral than on the legs abnormality earlier and more ○ Anterior cerebral artery clearly than other diagnostic tests. Weakness Can provide information about the Numbness on the opposite side chemical changes within cells, Personality changes allowing the clinician to monitor a Impaired motor and sensory tumor’s response to treatment. function Uses magnetic waves VERTEBROBASILAR ARTERY Patients with pacemakers, Posterior cerebral artery orthopedic metal prosthesis and Visual field defects implanted metal devices cannot Sensory impairment undergo this procedure Coma – prolonged state of NPO 4-6 hours before procedure unconsciousness; occurs when a ○ Angiography part of the brain is damaged, either ○ Cerebral Arteriography temporarily or permanently. Note allergies to dyes, iodine, and Less likely paralysis seafood Ensure consent Keep the patient at rest after the procedure Maintain pressure dressing or sandbag over the punctured site 8 NCM 118 – CARE OF CLIENTS WITH PROBLEMS WITH LIFE THREATENING CONDITIONS, ACUTELY ILL/MULTI-ORGAN PROBLEM, HIGH ACUITY & EMERGENCY ○ EEG (Electroencephalography) Abnormal – one side of the face Represents a record of the does not move as well as the other electrical activity generated in the side brain. ○ Arm Drift Useful for diagnosing and Have the patient close his/her eyes evaluating seizure disorders, coma, and hold both arms out. or organic brain syndrome; Normal – both arms move the determination of brain death. same way, or both arms do not Withhold medications that may move at all. interfere with the results- Abnormal – one arm does not anticonvulsants, sedatives, and move or one arm drifts down stimulants compared to the other arm. Other Wash hair thoroughly after the findings such as pronator grip, may procedure be helpful ○ LUMBAR PUNCTURE ○ Speech Ensure consent, determine ability Have the patient say “You can’t to lie still teach an old dog new tricks.” Contraindicated in patients with Normal – patient uses correct increased ICP words with no slurring. Keep flat on the bed after the Abnormal – patient slurs words, procedure uses inappropriate words or is Increase fluid intake after the unable to speak procedure MEDICAL MANAGEMENT LESSON 4: SEIZURE ○ TPA (Tissue Plasminogen Activator) For Ischemic stroke, NOT A seizure is a sudden, abnormal. excessive hemorrhagic discharge of electrical activity within the brain that Dissolves the clot by activating the disrupts the brains usual brain's usual system for protein causes fibrinolysis nerve conduction. Given within 3 hours from onset of ○ A seizure is a non-chronic disorder. signs and symptoms. ○ Epilepsy is a chronic disorder, Should transfer the patient to characterized by recurrent seizure activity. hospital within 1 hour. Seizures are episodes of abnormal motor, sensory, ○ Thrombolytics autonomic, or psychic activity (or a combination of Anticoagulants: Sodium heparin, these) that result from sudden excessive discharge warfarin (Coumadin) from cerebral neurons. Antiplatelets: Ticlopidine (Ticlid), ○ A localized area or all of the brain may be clopidogrel (Plavix), Aspirin involved. Antiepileptic: Phenytoin (Dilantin), The International League Against Epilepsy (ILAE) gabapentin (Neurontin) has defined epilepsy as at least two unprovoked ○ Stool softeners seizures occurring more than 24 hours apart. ○ Anti-hypertensives ○ The ILAE differentiates between three ○ Analgesics, Muscle relaxants, Steroids main seizure types: focal, generalized, CINCINNATI STROKE SCALE and unknown seizures. ○ Identifies patients with strokes. Three phases of seizure activity exist. ○ It evaluates three major physical findings. ○ First Phase Facial droop Prodromal phase, it consists of Motor arm weakness mood or behavioral changes that Speech abnormalities can precede seizures by hours or ○ Facial Droop days. Have the patient show their teeth An aura occurs in some individuals or smile. before the seizure. It is a sensory Normal – both sides of the face warning such as an unusual taste or move equally well smell, metallic taste, or flash of light. 9 NCM 118 – CARE OF CLIENTS WITH PROBLEMS WITH LIFE THREATENING CONDITIONS, ACUTELY ILL/MULTI-ORGAN PROBLEM, HIGH ACUITY & EMERGENCY Metabolic and toxic conditions ○ Second Phase (e.g., kidney injury, hyponatremia, Ictal phase is the seizure activity hypocalcemia, hypoglycemia, itself. pesticide exposure) ○ Third Phase Brain tumor Postictal phase follows the seizure. Drug and alcohol withdrawal Behavior changes, lethargy, or Allergies confusion can also occur. CLINICAL MANIFESTATIONS Classification of Seizures: 2016 Basic Scheme ○ Depending on the location of the ○ Focal discharging neurons, seizures may range Motor from a simple staring episode (generalized Nonmotor absence seizure) to prolonged convulsive Awareness movements with loss of consciousness. Aware ○ The initial pattern of the seizures Impaired awareness indicates the region of the brain in which Unknown awareness the seizure originates. ○ Generalized Only a finger or hand may shake, or Motor the mouth may jerk uncontrollably. Absence The person may talk unintelligibly; ○ Unknown may be dizzy; and may experience Motor unusual or unpleasant sights, Non-motor sounds, odors, or tastes, but Awareness without loss of consciousness. Aware ○ Generalized seizures often involve both Impaired awareness hemispheres of the brain, causing both Unknown awareness sides of the body to react. Unclassified Intense rigidity of the entire body PATHOPHYSIOLOGY may occur, followed by alternating ○ The underlying cause is an electrical muscle relaxation and contraction disturbance (dysrhythmia) in the nerve (generalized tonic-clonic cells in one section of the brain; these contraction). cells emit abnormal, recurring, The simultaneous contractions of uncontrolled electrical discharges. the diaphragm and chest muscles ○ The characteristic seizure is a may produce a characteristic manifestation of this excessive neuronal epileptic cry. discharge. The tongue is often chewed, and ○ Associated loss of consciousness, excess the patient is incontinent of urine movement or loss of muscle tone or and feces. movement, and disturbances of behavior, After 1 or 2 minutes, the convulsive mood, sensation, and perception may also movements begin to subside; the occur. patient relaxes and lies in deep CAUSES coma, breathing noisily. ○ The specific causes of seizures are varied ○ The respirations at this point are chiefly and can be categorized as genetic, due to abdominal. a structural or metabolic condition, or the ○ In the postictal state (after the seizure), cause may be yet unknown etiologies the patient is often confused and hard to ○ Causes of seizures include: arouse and may sleep for hours. ↳ Cerebrovascular disease Many patients report headache, Hypoxemia of any cause, including sore muscles, fatigue, and vascular insufficiency depression. Fever (childhood) Other generalized seizures may be Head injury absence types of seizures. Hypertension CNS infections 10 NCM 118 – CARE OF CLIENTS WITH PROBLEMS WITH LIFE THREATENING CONDITIONS, ACUTELY ILL/MULTI-ORGAN PROBLEM, HIGH ACUITY & EMERGENCY ○ Focal seizures are subdivided into events the stiffness begins, conjugate gaze characterized by both motor and position, and the position of the non-motor symptoms. head at the beginning of the There may be an impairment of seizure. This information gives clues consciousness or awareness or to the location of the seizure origin other dyscognitive features, in the brain. (In recording, it is localization, and progression of important to state whether the symptoms. beginning of the seizure was ASSESSMENT AND DIAGNOSTIC FINDINGS observed.) ○ The diagnostic assessment is aimed at Type of movements in the part of determining the type of seizures, their the body involved frequency and severity, and the factors Areas of the body involved (turn that precipitate them. back bedding to expose patient) A developmental history is taken, Size of both pupils and whether the including events of pregnancy and eyes are open childbirth, to seek evidence of Whether the eyes or head are pre-existing injury. turned to one side The patient is also questioned Presence or absence of about illnesses or head injuries that automatisms (involuntary motor may have affected the brain. activity, such as lip smacking or ○ MRI is used to detect structural lesions repeated swallowing) such as focal abnormalities, Incontinence of urine or stool cerebrovascular abnormalities, and Duration of each phase of the cerebral degenerative changes. seizure ○ EEG furnishes diagnostic evidence for a Unconsciousness, if present, and its substantial proportion of patients with duration epilepsy and assists in classifying the type Any obvious paralysis or weakness of seizure of arms or legs after the seizure ○ SPECT (Single Photon Emission Computed Inability to speak after the seizure Tomography) is an additional tool that is Movements at the end of the sometimes used in the diagnostic workup. seizure It is useful for identifying the Whether or not the patient sleeps epileptogenic zone so that the area afterward in the brain giving rise to seizures Cognitive status (confused or not can be removed surgically. confused) after the seizure NURSING MANAGEMENT – During a Seizure ○ In addition to providing data about the ○ A major responsibility of the nurse is to seizure, nursing care is directed at observe and record the sequence of signs. preventing injury and supporting the The nature of the seizure usually indicates patient, not only physically but also the type of treatment required. psychologically. Consequences such as ○ Before and during a seizure, the patient is anxiety, embarrassment, fatigue, and assessed and the following items are depression can be devastating to the documented: patient Circumstances before the seizure NURSING MANAGEMENT – After a Seizure (visual, auditory, or olfactory ○ After a patient has a seizure, the nurse’s stimuli; tactile stimuli; emotional or role is to document the events leading to psychological disturbances; sleep; and occurring during and after the seizure hyperventilation) and to prevent complications (e.g., Occurrence of an aura (a aspiration, injury). premonitory or warning sensation, ○ The patient is at risk for hypoxia, vomiting, which can be visual, auditory, or and pulmonary aspiration. olfactory) First thing the patient does in the seizure—where the movements or 11 NCM 118 – CARE OF CLIENTS WITH PROBLEMS WITH LIFE THREATENING CONDITIONS, ACUTELY ILL/MULTI-ORGAN PROBLEM, HIGH ACUITY & EMERGENCY ○ To prevent complications, the patient is ○ Nursing Care After the Seizure placed in the side-lying position to Keep the patient on one side to facilitate drainage of oral secretions, and prevent aspiration. Make sure the suctioning is performed, if needed, to airway is patent. maintain a patent airway and prevent On awakening, reorient the patient aspiration. to the environment. ○ Seizure precautions are maintained, If the patient is confused or including having available functioning wandering, guide the patient gently suction equipment with a suction catheter to a bed or chair. and oral airway. If the patient becomes agitated ○ The bed is placed in a low position with after a seizure (postictal), stay a two to three side rails up and padded, if distance away, but close enough to necessary, to prevent injury to the patient. prevent injury until the patient is CARE OF THE PATIENT DURING AND AFTER A fully aware SEIZURE EPILEPSIES ○ Nursing Care During a Seizure ○ Epilepsy is a group of syndromes Provide privacy, and protect the characterized by unprovoked, recurring patient from curious onlookers. seizures. (The patient who has an aura may Epileptic syndromes are classified have time to seek a safe, private by specific patterns of clinical place.) features, including age at onset, Ease the patient to the floor, if family history, and seizure type. possible. The epilepsies include Protect the head with a pad to electroclinical syndromes (a prevent injury (from striking a hard complex of clinical features, signs, surface). and symptoms) and other Loosen constrictive clothing and epilepsies. remove eyeglasses. Epilepsy can be primary (idiopathic) Push aside any furniture that may or secondary (when the cause is injure the patient during the known and the epilepsy is a seizure. symptom of another underlying If the patient is in bed, remove the condition, such as a brain tumor). pillows and raise the side rails. ○ The cause of seizures in many people is Do not attempt to pry open jaws idiopathic (unknown). that are clenched in a spasm or Epilepsy can follow birth trauma, attempt to insert anything in the asphyxia neonatorum, head mouth during a seizure. injuries, some infectious diseases ↳ Broken teeth and injury (bacterial, viral, parasitic), toxicity to the lips and tongue (carbon monoxide and lead may result from such an poisoning), circulatory problems, action. fever, metabolic and nutritional Do not attempt to restrain the disorders, or drug or alcohol patient during the seizure, because intoxication. muscular contractions are strong It is also associated with brain and restraint can produce injury. tumors, abscesses, and congenital If possible, place the patient on one malformations. side with head flexed forward, which allows the tongue to fall forward and facilitates drainage of saliva and mucus. ↳ If suction is available, use it if necessary to clear secretions. 12 NCM 118 – CARE OF CLIENTS WITH PROBLEMS WITH LIFE THREATENING CONDITIONS, ACUTELY ILL/MULTI-ORGAN PROBLEM, HIGH ACUITY & EMERGENCY ○ Medical Management The management of epilepsy is individualized to meet the needs of each patient and not just to manage and prevent seizures. Management differs from patient to patient, because some forms of epilepsy arise from brain damage and others result from altered brain chemistry. ○ Pharmacologic Therapy Many medications are available to control seizures, although the exact mechanisms of action are unknown. The objective is to achieve seizure control with minimal side effects. Medication therapy controls — rather than cures — seizures. Medications are selected on the basis of the type of seizure being treated and the effectiveness and safety of the medications. 13