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Fall Final 2006 (Lyn)


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What is epilepsy?
An abnormal, sudden, excessive discharge of electrical activity within the brain; a chronic condition.
What is primary epilepsy?
No underlying brain lesion.
What is secondary epilepsy?
Brain lesion, is not epilepsy.
Who has the highest incidence of epilepsy?
Older adults and children.
What are partial or focal seizures?
Epileptogenic focus limited to one region of one cerebral cortex, one hemisphere; common in adults. Consists of simple or complex.
What is a simple partial seizure?
-Patient remains conscious.
-Experiences aura (unusual sensation).
-A "deja vu" phenomenon.
-An offensive smell or feeling of pain.
-Unilateral movement of extremity.
-Autonomic symptoms: changes in HR and skin flushing.
-Psychic symptoms.
What is a complex partial seizure?
-Black out for 1-3 minutes.
-Automatism e.g. lip smacking or patting, pulling on clothes, etc.
-Amnesia may follow immediately after.
What is a generalized seizure?
Both hemispheres - Tonic-clonic, absence, myoclonic, atonic, unclassified.
What is a tonic-clonic seizure?
-Formerly grand mal
-lasts 2-5 minutes
-tonic: rigidity of arm or leg muscles
-immediate loss of consciousness
-Clonic: rhythmic jerking of all extremities.
-may bite tongue
-incontinence of urine or feces
-fatigue, lethargy & confusion, last an hour
What is an absence seizure?
-formerly petit mal
-more in children
-brief period of loss of consc. (seconds)
-blank staring, like daydreaming
-return to baseline immediatly after
What is a myoclinic seizure?
-brief jerking or stiffening of extremities; single or group
-lasts just a few seconds
What is an atonic (akinetic) seizure?
-formerly, drop attack
-sudden loss of muscle tone
-patient may fall
-postictal (post attack): confusion
What are unclassified seizures?
-1/2 of all seizures
-occur for no reason or fit no classification
What is an acute seizure?
-greater intensity, number or length is considered acute
-or may appear in clusters
-treatment with Lorazepam (Ativan) or Diazepam (valium); rectal gel
-goal to stop clusters and prevent status epilepticus
What is Status Epilepticus?
-continuous or recurrent generalized seizures, in rapid succession
-does not regain full consciousness between seizures
-repeated ones lasting over 30 minutes or one lasting over 10 mins
-more intense than patient's usual
-a potential complication for all types of epilepsy
-Medical Emergency!!! - a death or brain damage can result from prolonged hypoxia & cardiac dysrhythmia, lactic acidosis
What causes Status Epilepticus?
-sudden withdrawal from anticonvulstants
-head trauma; cerebral edema
Care during Status Epilipticus?
-maintain ABC's
-O2 via nasal cannula
-inform physician, endotracheal intubation may be needed
-access vein, start IV NS
What are some medications used during Status epilepticus?
-ativan or diazepam followed by dilantin
-Fosphenytoin (cerebyx) can be IM
Nurse's interventions during Status Epil.?
-appropriate for type of epilepsy
-may be just observe, document time & length of seizure (partial seizure)
-cyanosis may occur in TC seizure - 02 via nasal acannula to high risk patients (e.g. old or debilitated)
More nursing interventions during Status Epil?
-make sure they are safe
-protect their airway
-remain calm
-never leave person alone
-lower to floor or bed
-move objects out of the way
-loosen constrictive clothing
-turn head or body to one side
-do not attempt to restrain or hold down
-do not force anything into mouth
-do no use pillows due to danger of suffocation
Nursing care during Status Epil?
-note duration & characteristics of seizure; observe events carefully
-allow seizure to end without interference; note postical events
-when stops, check for breathing
-if none, start rescue breathing and call for help
-if child, check around mouth for signs of burns or suspicious substances that may indicate poisoning
Nursing implications in infusing manitol?
-Use of filter in IV tubing - there is an inline filter
What is meningitis?
-An inflammation of the meninges of the brain & spinal cord.
-Usually bacterial or viral.
-Could be fungus or parasites.
Which meningitis is more common?
Bacterial - early detection can lead to a favorable outcome.
What is bacterial meningitis?
-Common in winter & fall with upper respiratory infection.
-Meningococcal type occurs in outbreaks.
-In areas with high density population.
Is there a vaccination available for bacterial meningitis?
-Vaccination is available.
-Use of vaccine against Haemophilus Influenza leads to dramatic change in epidemiology.
-However, meningitis by other microorganisms are still very serious disease in children.
-Leave serious damage, if undiagnosed or under treated.
How is bacterial meningitis transmitted?
-Transmission is basically by droplet.
-Requires droplet isolation.
What are some predisposing conditions for bacterial meningitis?
-Otitis media, acute sinusitis
-Fractured base of skull with CSF leak
-Procedures like LP or surgery
-Anatamic abnormalities like spina bifida
-Foreign objects like ventricular shunts
-Transmission can occur from a focal infection via blood
What is viral meningitis?
-aseptic meningitis
-often a complication of a viral infection
-mumps, measles or herpes simplex
-herpes virus can change cellular metabolism & result in necrosis
Differences between bacterial and viral meningitis?
Bacterial - serious, abrupt onset, leaves sequellae.

Viral - usually self limiting, follows viral infection.
Specific S/S of meningitis?
-Nuchal rigidity (stiff neck)
-Kernig's sign
What is Kernig's sign?
Severe stiffness of the hamstrings causes an inability to straighten the leg when the hip is flexed to 90 degrees.
What is Brudzinski's sign?
One of the physically demonstrable symptoms of meningitis - severe neck stiffness causes a patient's hips and knees to flex when the neck is flexed.
What is opisthotonus?
Severe spasm in which the back arches and the head bends back and heels flex toward the back.
What is nuchal rigidity?
Stiffness of the neck.
What causes meningitis?
-Most common causes of meningitis are viral infections that usually resolve without treatment.
-However, bacterial infections of the meninges are extremely serious illnesses, and may result in death or brain damage even if treated.
-Also caused by fungi, chemical irritation or drug allergies, and tumors.
Assessment of bacterial meningitis?
-Onset usually abrupt
-Fever, chills, unrelenting headache
-Symptoms of IICP
-Can lead to brain herniation & death
-Infant/child feeds poorly or refuses
-SIADH occurs and leads to water retention & further IICP
-Water retention is coupled with hyponatremia (hemodilution & excess excretion
-vomiting or diarrhea
-Seizures due to irritation of brain cortex
-Photophobia, nystagmus
-DIC due to septic emboli
-Possible petechial rash in infant/child
-Hemiparesis, change in LOC
-Signs of meningeal irritation
What are signs of meningeal irritation?
-nuchal rigidity - stiff neck, especially when neck flexed
-Kernig's sign
-Pain is due to meningeal irritation & spinal nerve root inflammation
-Brudzinski's sign
-Stupor & coma
How are seizure managed nonsurgically?
-Most are almost completely congrol with antiepileptic medications.
-Introduce one drug at a time.
-Sometimes only combination works.
-Goal: therapeutic effect with minimum dose, without major side effects.
-Ideally seizures should be controlled with one med. esp in children.
-Administer meds on time to achieve therapeutic levels.
-Teach children & family to watch out for side effects.
-Watch for drug-drug, & drug-food interaction e.g. dilantin & coumadin
-Vagal nerve stimulation with a prosthetic device that is implanted in the chest; electrode attached to left vagus nerve. (Only for certain specific cases. Stimulation of vagus can be client controlled.
How are seizures managed surgically?
-Last resort for patient not controlled.
-Goal is to improve quality of life.
-Tests are done to see which hemisphere has the language center.
-Also memory & intelligence etc.
What are the main neuro meds?
-Mannitol - osmotic diuretic
-Lasix - loop diuretic
-Prednisone, Solu-Medrol, Decadron - Glucocorticoids
-Heparin, Coumadin - Anticoagulants
-Persantine, Ticlid, Aspirin - Antiplatelets
-codeine, NSAIDs - Analgesics
-Alteplase (tPA) - Thrombolytic agent
-Phenobarbital, diazapams, Ativan - Sedatives, tranquilizers
-Dilantin, Tegretol, Depakote, Cerebyx, neruotin (SE) - Anticonvulsants
-Amicar - Hemostatic agent
-Ampicillin, cephalosporins, Gentamycin - antiinfectives
What should you teach you patient about Dilantin?
-is an anti-epileptic. It works by slowing down impulses in the brain that cause seizures.
-is used to control seizures.
-may also be used for purposes other than those listed in this medication guide.
-Do not stop taking even if you feel better. It is important to continue taking the medication to prevent seizures from recurring.
-Do not change brands of phenytoin without first talking to your doctor or pharmacist. Some brands of phenytoin are interchangeable while others are not. Your doctor and/or pharmacist know which brand/generic formulations may be substituted for another.
-Do not crush, chew, or break the capsules. Swallow them whole. They are specially formulated to release the drug slowly into the body.
-Carry or wear a medical identification tag to let others know that you are taking this medicine in the case of an emergency.
What is a stroke?
-Brain attack; a medical emergency; like a heart attack.
-Treated immediately, prevents neurological deficit & permanent disability.
-3rd cause of death in USA.
-Primary cause of adult disability.
Types of strokes?
- Thrombotic
- Embolic
What is an ischemic stroke?
Caused by a thrombus or emboli occluding cerebral artery: includes thrombotic & embolic.
What is a thrombotic stroke?
- slow onset
- accounts for more than half of all strokes
- caused by atheroschlerosis of arteries
- first transient & then permanent ischemia & infarction occurs
- the area of infarction becomes edematous & necrotic; cavaties are formed
What is an embolic stroke?
- 1/3 of all strokes
-embolus or emboli break off from other parts of body & enter cerebral circulation via the carotid
What is hemorrhagic stroke?
-vessel breaks down; bleeding into brain tissue, subarachnoid space or ventricles
-caused by: HTN, aneurysm, AV malformation, vasospasm that follows rupture of artery, marked diminishment in cerebral perfusion
What are the causes/risk factors for strokes?
-HTN & diabetes
-Heart disease (Afib)
-High blood cholesterol
-Hypercoagulability state
-Drug abuse (cocaine)
-Many other with no genetic element
What are some warning signs of ischemic stroke?
-Transient ischemic attack (TIA)
-Reversible ischemic neurological deficit (RIND)

Both are due to cerebral HTn or vasospasm and due to short term interruption of blood flow. They both show focal neuro deficit and slow brain damage occurs in both.
Neuro assessment in stroke?
-LOC varies depending on extent of IICP
-Proprioceptive dysfunction
-Impairment in judgment, decision making, problem solving & memory
-Inability to concentrate or perform tasks
-Personality changes - impulsiveness & poor judgment
Assessment for hemonymous hemianopsia in stroke?
Visual field deficits
Neglect syndrome in strokes?
Being unaware of the paralyzed side.
Asphasia in stroke?
Cannot use (expressive) or understand (receptive)language.
What is alexia?
Reading problems
What is Agraphia
Writing difficulties
What is hemiplegia?
Total paralysis of the arm, leg, and trunk on the same side of the body.
What is hemiparesis?
Weakness on one side of the body.
What is hypotonia?
Drooping shoulder, dragging extremities.
What is apraxia?
Inability to perform previously learned motor skills or command.
What is Hemianopsia?
Blindness in one half of visual field.
Drugs used for stroke?
-Anticoagulants & antiplatelets
-Antiepileptics - Dilantin, Neurotin
-Calcium channel blockers
-Other therapies: nonconclusive.
What do thrombolytics do?
-Prevent cerebral infarction; rt-PA drug of choice.
-Give within 3 hours of stroke only.
-Client should meet criteria.
What do Anticoagulants & antiplatelets do?
-If received thrombolytics, follow with IV anticoagulant
-Aspirin, heparin, Lovenox, Coumadin
-Keep coagulation profile: PT or PTT 1.5-2 times patient's baseline and INR value of 2-3. For stroke of cardiac origini - 3-4.5
-Anticoagulants contraindicated in ulcer, uremia, hepatic failure.
What do antiepileptics do?
-Prevent seizures - dilantin, neurontin
what do calcium channel blockers do?
-treat cerebral vasospasm that occurs after 4-14 days.
Dexamethasone side effects?
-Chronic use will lead to adrenal suppression.
-Chronic use in children inhibits growth, and the lowest possible dose should be used over the shortest period of time.
-most common side effects are depression, euphoria, hypertension, nausea, anorexia, decreased wound healing, acne, muscle wasting, bone pain, and increased susceptibility to infection.
What does dexamethasone do?
Suppresses inflammation and normal immune response, and is used systemically and locally to treat chronic inflammatory disorders, severe allergies, and other diseases.
Surgical treatment for CVA?
-Carotid endarterectomy - removal of atherosclerotic plaque from the lining of carotid artery.
-Revascularization (arterial bypass graft): a bypass graft around occluded artery; e.g., middle temporal artery to middle cerebral artery.
What should you monitor after a carotid endarterectomy?
-neuro/vital signs
-tongue deviation
-facial weakness
-bleeding at incisional site
-swelling of neck or c/o dysphagia
What should you monitor after an arterial bypass graft?
-circulation in anastomosed vessel
-graft area free of pressure
What is a Cerebral Aneurysm?
-A ballooning or blister on arterial wall.
-congenital or traumatic
-often on the branching of major cerebral arteries
-weakened, thinned arterial wall
-ruptures with continuous force on blood vessel like HTN
-can be the source of embolism
What causes cerebral aneurysms?
-smoking & HTN, contributing factors
-rupture happens during activity, although may occur at any time
-leads to intracerebral hematoma or bleeding into subarachnoid space, or directly into ventricles
-vasoconstriction follows in response
S/S of cerebral aneurysm rupture?
-sudden explosive headache
-neck rigidity (due to blood in CSF)
-nausea & vomiting
-LOC, brain ischemia
-resp. distress
Types of brain tumors?
-Gliomas (malignant)
Preop Prep for cranial surgery?
-pt./family teaching
-allow verbalization of fears
-prepare family for appearance of pt. postop
-signed consent form
-NO enemas
-shampoo hair
-shaving of head usu. done in OR
Postop care for craniotomy?
-monitor ventilation status
-monitor neuro status
-assess for drainage
-initial dressing to be reinforced as needed
-measure & mark drainage on dressing
-place on side immediately after surgery
-further positioning per surgeon
What different position should the patient be put in after brain surgery?
-supratentorial: HOB 30-45 degrees with a large pillow under head & shoulders
-infratentorial: HOB flat with small pillow; log roll with draw sheet; no neck flexion
-craniectomy: do not place on affected side

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