NR 341 Week 6 Complex Intracranial – Neurological Alterations

NR 341 Week 6 Complex Intracranial – Neurological Alterations

NR 341 Week 6 Complex Intracranial – Neurological Alterations

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Chamberlain University

NR-341 Complex Adult Health

Prof. Name

Date

WEEK 6 EDAPT NOTES: COMPLEX CARE NR 341

Complex Intracranial – Neurological Alterations

Intracranial regulation refers to the body’s ability to manage blood and cerebrospinal fluid flow within the brain and spinal cord. This is governed by a sensitive system of nerve fibers that detect variations in pressure and flow, adjusting accordingly to maintain homeostasis. Injuries or abnormalities can disrupt this balance, necessitating adjustments by the nervous system. In some cases, these adjustments are insufficient, requiring external intervention to restore normal function. For example, if a client has a mean arterial pressure of 120 mm Hg and an intracranial pressure of 42 mm Hg, the cerebral perfusion pressure is calculated as the mean arterial pressure minus the intracranial pressure, yielding a cerebral perfusion pressure of 78 mm Hg.

When intracranial pressure is significantly elevated, a nurse may anticipate symptoms such as bradycardia, irregular respiration patterns, and widening blood pressure measurements, collectively known as Cushing’s triad. These symptoms can indicate the risk of impending cerebral herniation. Furthermore, bloody drainage from the ear may indicate a skull fracture, while cold and clammy skin below the neck may suggest autonomic dysreflexia. To assess a client’s level of consciousness accurately, the Glasgow Coma Scale (GCS) is the preferred tool. The balance of cerebrospinal fluid and blood is crucial, as intracranial pressure changes when there are alterations in brain tissue, cerebrospinal fluid, or blood volume. The body can compensate for minor changes by adjusting blood pressure or cerebrospinal fluid flow, a process known as intracranial regulation.

Altered Intracranial Regulation

Altered intracranial regulation can arise when there are unexpected changes in mass due to space-occupying lesions or increased swelling from an inflammatory response. This condition may develop gradually, as seen in brain tumors, or rapidly, as in cases of cerebral edema caused by inflammation or bleeding. Changes in the volume of brain tissue, cerebrospinal fluid, or blood can lead to fluctuations in intracranial pressure, which can, in turn, result in symptoms of decreased brain perfusion, as measured by cerebral perfusion pressure (CPP). In managing clients with complex health issues, advanced monitoring techniques are employed to measure intracranial pressures accurately. This may involve the use of drains and other devices to reduce pressure by draining cerebrospinal fluid or inducing coma and artificial ventilation to lower intracranial pressure.

In complex healthcare environments, monitoring intracranial pressure can be achieved through the placement of a catheter within the skull, providing continuous measurements that help identify elevated pressures or changes in brain temperature. Notably, the most severe complication of altered intracranial regulation is herniation, which occurs when extreme pressure inside the skull forces the brain stem through the foramen magnum, leading to severe outcomes such as death or significant brain damage. Normal ranges for these measurements are as follows:

  • Mean arterial pressure (MAP): 70 to 100 mm Hg
  • Intracranial pressure (ICP): 5 to 15 mm Hg
  • Cerebral perfusion pressure (CPP): 60 to 80 mm Hg

There are several methods for monitoring intracranial pressure, including:

  • Intraventricular Catheter: A flexible tube inserted into the lateral ventricle of the brain, providing accurate measurements and allowing for the drainage of excess cerebrospinal fluid.
  • Subdural Screw (or Bolt): A hollow screw inserted through a drilled hole in the skull, which reads the pressure in the subdural space and can be quickly installed.
  • Epidural Sensor: Placed between the skull and dural tissue, this is the least invasive method but does not allow for drainage of cerebrospinal fluid.

Alongside monitoring intracranial pressure, other metrics that may be assessed in complex situations include blood flow, oxygenation, metabolism, and continuous electroencephalographic monitoring. Research into the efficacy of different monitoring techniques continues to enhance patient care for those with altered intracranial regulation.

Spinal Cord Injury

Spinal cord injuries are critical neurological alterations that require immediate attention in complex healthcare environments. The spinal cord can suffer from bruising, punctures, or severing. Since the spinal cord extends from the neck down to the first and second lumbar vertebrae, damage at any point can lead to symptoms extending beyond the injury site. For example, injuries in the cervical region can affect respiratory function, while damage above the thoracic vertebrae (T6) can result in cardiovascular symptoms such as bradycardia, hypotension, and impaired vascular response. Injuries at the thoracic level may cause bowel and urinary dysfunction, including urinary retention and constipation.

The specific spinal nerves include:

  • Cervical nerves (cervic/o)
  • Thoracic nerves (thorac/o)
  • Lumbar nerves (lumb/o)
  • Sacral nerves (sacr/o)
  • Coccygeal nerve (coccyg/o)

Acute Spinal Cord Injury

The severity and location of a spinal cord injury dictate the extent of paralysis and the organs affected. Depending on the injury’s severity, clients may experience complete paralysis (if the cord is severed) or temporary paralysis and paresthesia (in cases of bruising). For instance, an injury at the T6 level may lead to gastrointestinal issues like constipation, fecal impaction, and abdominal bloating, contingent on the injury’s specifics, the quality of care provided, and proactive bowel management.

The following table summarizes the impact of various spinal cord injuries on function:

Injury LevelDescriptionEffects
C1-C3High quadriplegiaInability to breathe or cough
C4High quadriplegiaSignificant respiratory impairment
C6Low quadriplegiaMild respiratory effects
T6High paraplegiaCardiovascular and gastrointestinal issues
L1Low paraplegiaBladder dysfunction

Altered intracranial regulation or other neurological changes can stem from various causes, as indicated by specific cues from the client’s history:

Past Medical History:

  • Previous head injury
  • Brain hematomas (epidural, subdural, or subarachnoid)
  • Cerebral vascular accidents leading to brain edema
  • Ruptured cerebral blood vessels
  • Overproduction of cerebrospinal fluid (pseudotumor cerebri)
  • Meningeal inflammation or infection
  • Vertebral fractures
  • Osteoporosis
  • Degenerative disc disease

Past Surgical History:

  • Previous brain surgeries
  • Previous spinal surgeries

Family History:

  • Seizures
  • Parkinson’s disease
  • Huntington’s chorea

Social History:

  • Prolonged anoxia (near drowning)
  • Past trauma to the head or spine
  • Occupational exposure to neurotoxins

Medications:

  • Antiseizure medications indicating a history of neurological issues
  • Anticoagulants posing a risk for cerebral hemorrhage
  • Psychotropic medications with neurological side effects
  • Serotonin-inducing drugs linked to serotonin syndrome

Conditions such as dyslipidemia, concussions, and bacterial meningitis can also disrupt intracranial regulation. A history of these conditions alerts nurses to patients at higher risk for altered regulation. Surgical procedures like lumbar laminectomies can introduce complications, potentially creating scar tissue that affects cerebrospinal fluid flow. Additionally, smoking may elevate the risk of cerebrovascular diseases, and a family history of such diseases could heighten the client’s risk as well.

Symptoms of Complex Neurological Problems

Level of Consciousness Problems:

  • Altered consciousness
  • Confusion
  • Impaired memory and orientation

Brain-Connected Nerve Issues:

  • Visual disturbances (blurred or double vision)
  • Hearing impairments (unequal or absent hearing)
  • Anosmia (loss of smell)
  • Dysphagia or dysgeusia (swallowing or taste difficulties)
  • Impaired neck or shoulder movement

Movement Issues:

  • Paralysis (inability to move)
  • Paresthesia (loss of sensation or abnormal sensations)
  • Abnormal reflexes

Pain Symptoms:

  • Headaches (considering location, duration, and intensity)
  • Extremity pain

Airway Clearance and Gas Exchange:

  • Breathing difficulties

Elimination Issues:

  • Urinary retention or incontinence
  • Fecal retention or incontinence

Reproductive Issues:

  • Erectile dysfunction
  • Anorgasmia

Level of Consciousness Assessment

The Glasgow Coma Scale (GCS) evaluates a client’s level of consciousness through eye-opening, verbal, and motor responses:

Eye Opening Response:

  • Spontaneous: 4 points
  • To verbal stimuli: 3 points
  • To pain only: 2 points
  • No response: 1 point

Verbal Response:

  • Oriented: 5 points
  • Confused conversation: 4 points
  • Inappropriate words: 3 points
  • Incomprehensible speech: 2 points
  • No response: 1 point

Motor Response:

  • Obeys commands: 6 points
  • Purposeful movement to pain: 5 points
  • Withdrawal from pain: 4 points
  • Flexion to pain: 3 points
  • Extension to pain: 2 points
  • No response: 1 point

Vital Signs:

  • Fever
  • Cushing’s triad
  • Irregular breathing patterns
  • Bradycardia
  • Widening pulse pressure

Brain-Connected Nerve Assessment:

  • Comprehensive evaluation of cranial nerves, including:
    • I: Olfactory (smell)
  • II: Optic (vision)
    • III: Oculomotor (eye movement)
    • IV: Trochlear (eye movement)
    • V: Trigeminal (facial sensation, mastication)
    • VI: Abducens (eye movement)
    • VII: Facial (facial expressions, taste)
    • VIII: Vestibulocochlear (hearing, balance)
    • IX: Glossopharyngeal (taste, swallowing)
    • X: Vagus (autonomic functions)
    • XI: Accessory (shoulder movement)
    • XII: Hypoglossal (tongue movement)

Assessment Techniques:

  • Measure vital signs
  • Perform a detailed neurological assessment
  • Observe pupil size and reactivity
  • Assess limb strength and movement
  • Evaluate sensory responses
  • Examine the abdomen for signs of distension or discomfort

In summary, careful assessment and monitoring are essential in managing complex care clients, particularly those experiencing altered intracranial regulation or spinal cord injuries.

Primary Nursing Diagnosis and Evaluation

Primary Nursing DiagnosisNursing Evaluation
Acute confusionThe client demonstrates alertness and orientation to person, place, time, and situation.
Decreased intracranial adaptive capacityThe Glasgow Coma Scale score is 15, indicating full consciousness.
Ineffective thermoregulationThe client maintains an oral temperature ranging from 97.8ºF (36.6ºC) to 99.8ºF (37.7ºC).
Impaired memoryThe client is able to articulate both short- and long-term memories.
Autonomic dysreflexiaThe client shows no symptoms of autonomic dysreflexia.
Altered perfusionThere are no indications of decreased cerebral perfusion in the client.
Impaired mobilityThe client exhibits normal reflexes, moves all extremities, maintains balance, and reports no paresthesia.
PainThe client communicates that their pain level is manageable.

Secondary Nursing Diagnosis and Evaluation

Secondary Nursing DiagnosisNursing Evaluation
Altered perfusionMean arterial pressure is sustained between 60 and 100 mm Hg.
Reduced cardiac outputMean arterial pressure is maintained between 65 and 100 mm Hg.
Impaired airway clearanceThe client maintains a clear and open airway.
Altered gas exchangeOxygen saturation levels remain above 92%, with a respiratory rate between 12 and 20 breaths per minute.
ConstipationThe client adheres to a normal bowel routine.
Urinary retentionUrine output is consistently above 30 mL/hour, with no residual urine detected in the bladder.
Incontinence (bowel or bladder)The client’s skin remains dry and free of urinary or fecal moisture.
Altered tissue integrityThe client’s skin remains intact and free of lesions.
Altered nutritionAlbumin blood levels are consistently above 3.5 g/dL.

According to the National Spinal Cord Injury Statistics Center (2020), approximately 300–400 individuals sustain spinal cord injuries annually. Nearly three-quarters of these injuries stem from motor vehicle accidents, falls, gunshot wounds, and motorcycle accidents. Preventive measures should emphasize safe driving practices, including enhanced speed enforcement and the consistent use of seat belts and airbags. Additionally, increased safety gear usage when working at heights and improvements in gun control and motorcycle safety are vital areas for prevention.

Causes of Spinal Cord Injury

CausePercentage (%)
Auto crash32
Fall23.1
Gunshot wound15.2
Motorcycle crash6.1
Diving5.7
Medical complication2.9
Hit by falling/flying object2.7
Bicycle1.7
Pedestrian1.5

Post-injury, the primary causes of mortality in clients with spinal cord injuries include:

  • Diseases of the respiratory system (21.4%)
  • Infective and parasitic diseases (12%)
  • Neoplasms (10.8%)
  • Heart disease (10.4%)

In acute care settings for spinal cord injuries, it is crucial to address the secondary effects of the injury. The top priorities always include maintaining airway, breathing, and circulation. Clients must be immobilized to prevent further damage to the spinal cord.

Elderly patients may present complex intracranial regulation issues that can be confused with age-related changes or new-onset dementia. Therefore, a comprehensive medical and medication history is vital for identifying potential causes of altered intracranial regulation that may be less apparent in younger clients. Medications can interfere with blood clotting mechanisms, and certain activities, such as shaving or walking barefoot, pose risks for bleeding. Unwitnessed falls may also suggest underlying injuries that could be life-threatening.

NR 341 Week 6 Complex Intracranial – Neurological Alterations

In younger populations, intracranial regulation problems are often due to traumatic injuries or congenital issues such as spina bifida, cerebral palsy, or congenital malformations that lead to hydrocephalus. These individuals may experience chronic neurological problems as they age. Birth history and any childhood trauma are essential factors to review with the client.

For instance, Angela Everheart, a 57-year-old female brought to the emergency department (ED), presented with a Glasgow Coma Scale score of 4. This score is based on assessments indicating that her eyes do not open and she is verbally unresponsive. Additionally, she exhibited “decerebrate posturing” and had an unequal dilated pupil on the right side. Other concerning signs included widening systolic and diastolic blood pressure, bradycardia, and absent respirations with an inability to obtain an oxygen saturation reading.

Glasgow Coma Scale Eye Opening Response:

  • Spontaneous: opens with blinking at baseline (4 points)
  • To verbal stimuli, command, speech (3 points)
  • To pain only (not applied to face) (2 points)
  • No response (1 point)

Verbal Response:

  • Oriented (5 points)
  • Confused conversation but able to answer questions (4 points)
  • Inappropriate words (3 points)
  • Incomprehensible speech (2 points)
  • No response (1 point)

Motor Response:

  • Obeys commands for movement (6 points)
  • Purposeful movement to painful stimulus (5 points)
  • Withdraws in response (4 points)
  • Flexion in response to pain (decorticate posturing) (3 points)
  • Extension response in response to pain (decerebrate posturing) (2 points)
  • No response (1 point)

The absence of respirations suggests respiratory arrest. Signs of abnormal pupils, decreased Glasgow Coma Scale scores, widening pulse pressure, and bradycardia may indicate increased intracranial pressure. Autonomic dysreflexia is closely associated with skin assessment changes in spinal cord injury patients, sharing symptoms with neurogenic shock. An epidural hematoma represents an emergency that can develop within 24 hours of a head injury.

Nursing Diagnosis and Potential Actions

Nursing DiagnosisAssessment CuesPotential Nursing Actions
Decreased intracranial adaptive capacityReduced level of consciousness, cranial nerve abnormalitiesElevate the head of the bed above 30 degrees, hyperventilate, assist with cerebrospinal fluid catheter insertion and drainage.
Altered perfusionMean arterial pressure inconsistenciesAdminister blood pressure-lowering medications.
Impaired airway clearanceCompromised breathingReposition the head, neck, and jaw to ensure airway patency; prepare suction equipment and emergency airway supplies.
Altered gas exchangeLow oxygen saturation and decreased respirationAdminister oxygen as prescribed; prepare for artificial ventilation.

The sequence of nursing actions, prioritized from high to low, includes:

  1. Repositioning the head, neck, and jaw to open the airway.
  2. Obtaining an airway using emergency equipment if the client cannot breathe independently.
  3. Initiating artificial ventilation.
  4. Administering oxygen as prescribed.
  5. Administering medications to reduce blood pressure.
  6. Elevating the head of the bed above 30 degrees to aid in decreasing intracranial pressure.

The Arizona Department of Health has allocated a $1 million grant aimed at implementing strategies to reduce spinal cord injuries statewide. Public health nurses should recommend preventative measures that will benefit the largest demographic. Given that one-third of spinal cord injuries occur due to motor vehicle accidents, advocating for enhanced speed reduction strategies and increased seat belt usage would likely impact the greatest number of individuals. In contrast, diving and motorcycle accidents account for only 6% of spinal cord injuries, indicating that while new safety measures may help, they would not affect as many people. The same rationale applies to gun regulation.

Nursing Goals and Actions

Nursing GoalNursing Actions
Maintain normal bowel routineAdminister stool softeners as needed.
Maintain skin integrityUse barrier creams, provide bed padding, and ensure frequent sheet changes.
Maintain normal nutritionMonitor daily weights, keep detailed intake and output records, provide dietary consultations, and administer tube feedings as necessary. Albumin levels must remain above 3.5 g/dL.
Regulate body temperatureProvide a cooling or warming blanket to maintain a temperature between 97.8ºF and 99.8ºF.
Promote mobility and muscle strengthEncourage active or passive range of motion exercises and consult with physical therapy.

Head Injury Considerations

Head injuries are frequent occurrences in the United States, typically resulting from blunt force trauma due to automobile accidents, falls, workplace injuries, or violence. Cerebral contusions can lead to increased intracranial pressure due to cerebral edema. A basilar skull fracture allows blood and edema to escape outside the skull, whereas a spinal cord injury may cause localized edema but is less likely to elevate intracranial pressure. Scalp lacerations are external injuries that do not penetrate the brain but may indicate underlying blunt force trauma.

Coup-contrecoup injuries occur due to rapid deceleration

forces resulting in brain damage. Traumatic brain injuries can result in significant deficits, including memory impairment and loss of balance. Injury severity is classified using the Glasgow Coma Scale, which provides a reliable assessment of conscious awareness.

Head Injury Assessment and Nursing Considerations

At the scene of the incident, Sally experienced a brief loss of consciousness, after which she regained the ability to communicate without issues. However, within an hour, her condition deteriorated as she became increasingly drowsy and less responsive to inquiries. She vomited once and complained of a headache. Given Sally’s symptoms, an epidural hematoma is the most likely diagnosis. This condition typically presents with a loss of consciousness, followed by a lucid interval, after which the individual’s consciousness declines. Symptoms associated with an epidural hematoma may include headaches, nausea, and vomiting. In contrast, a subdural hematoma usually leads to a gradual decline in consciousness over 24 to 48 hours, while a concussion generally does not involve loss of consciousness. Intraventricular hemorrhage often results in focal neurological symptoms such as paralysis. For any patient with a head injury, a thorough assessment is essential to identify additional factors that might influence the severity of the injury and the challenges related to recovery.

Assessment Factors

To effectively assess a client with a head injury, it is critical to consider the following factors:

CategoryAssessment Factors
Past Medical History– Previous head injuries (old/new symptoms)
– Brain hematoma history (risk of rebleeding)
– History of cerebral vascular accidents (cerebral edema or abnormal neurologic status)
– Ruptured cerebral blood vessels (risk of rebleeding)
– Overproduction of cerebrospinal fluid (CSF) or presence of a ventricular peritoneal shunt
Past Surgical History– Brain surgery (potential for aggravation of existing injury or scar tissue)
– Spinal surgery (previous abnormalities)
Family History– Seizure history (higher seizure risk with new head injury)
Social History– Prolonged anoxia (comparison with prior assessments)
– Risk-taking behaviors (increased risk of reinjury)
– History of abuse (possible undisclosed injuries)
– Drug addiction (neurological changes due to withdrawal)
– Participation in contact sports (risk for post-concussive syndrome)
Medication– Anticoagulants (increased risk for hematomas and complications)
– Anti-seizure medications (higher seizure risk in clients with a seizure history)

The assessment of a client with a head injury should prioritize immediate injury evaluation and the potential for cerebral edema. Due to the seriousness of head injuries, assessments should be conducted in a rapid sequence to identify urgent nursing interventions. Notably, changes in airway and blood pressure are frequently associated with cerebral edema or hemorrhage and can be life-threatening if not addressed promptly.

Immediate Nursing Actions and Assessment

In cases of severe head trauma resulting in unconsciousness, assessing cranial nerve function is essential to gather pertinent information about the patient’s condition. Specifically, the Oculomotor nerve (cranial nerve III) should be assessed for pupillary response to light, as changes in the speed and size of the pupils can indicate significant head injury. Unlike other cranial nerves, this nerve can be assessed even if the patient is not fully conscious.

In the event of skull fractures, various signs and symptoms can indicate the fracture location:

Fracture LocationSigns and Symptoms
Basilar– CSF or brain otorrhea
– Bulging tympanic membrane from blood or CSF
– Battle’s sign
– Tinnitus or hearing difficulties
– Rhinorrhea
– Facial paralysis
– Conjugate gaze deviation
– Vertigo
Frontal– Exposure of brain through frontal air sinus
– Possible air presence in forehead tissue
– CSF rhinorrhea
– Pneumocranium (air between cranium and dura mater)
Orbital– Periorbital bruising (raccoon eyes)
– Optic nerve injury
Parietal– Deafness
– CSF or brain otorrhea
– Bulging tympanic membrane from blood or CSF
– Facial paralysis
– Loss of taste
– Battle’s sign
Posterior fossa– Occipital bruising leading to cortical blindness
– Visual field defects
– Rare ataxia
– Other cerebellar signs
Temporal– Boggy temporal muscle due to blood extravasation
– Oval-shaped bruise behind the ear (Battle’s sign)
– CSF otorrhea
– Middle meningeal artery disruption
– Epidural hematoma

Nursing Diagnoses and Potential Actions

The nursing diagnoses for patients with head injuries may include acute confusion, decreased intracranial adaptive capacity, ineffective tissue perfusion, ineffective thermoregulation, impaired memory, pain, imbalanced nutrition, and risk for infection. Each diagnosis presents unique assessment cues:

Nursing DiagnosisAssessment Cues
Acute Confusion– Disorientation
– Reduced alertness
Decreased Intracranial Adaptive Capacity– Unresponsiveness to verbal, auditory, or painful stimuli
– Cushing’s triad
– Cranial nerve abnormalities
Ineffective Tissue Perfusion– Altered level of consciousness
Ineffective Thermoregulation– Fever or hypothermia
Impaired Memory– Temporary or permanent memory loss
Pain– Severe headaches
– Neuropathy
Imbalanced Nutrition– Decreased albumin
– Inability to eat
Risk for Infection– Fever
– Erythema or pustular drainage

To address decreased intracranial adaptive capacity and ineffective tissue perfusion, nursing actions may include elevating the head of the bed, administering antihypertensives, hyperventilating if on a ventilator, inducing a coma, administering diuretics and anti-inflammatories, and assisting with drainage or craniotomy as needed. For clients with imbalanced nutrition and risk for infection, nursing actions may involve administering tube feedings, documenting strict intake and output, daily weighing, turning or moving patients every two hours, changing dressings for external devices, and ensuring hand hygiene.

Medications for Head Injury Management

The management of acute head injury may involve various medications:

MedicationPurpose
MannitolOsmotic diuretic that increases plasma osmolality to reduce cerebral edema
FurosemideLoop diuretic used to reduce plasma volume and cerebral edema
DexamethasoneGlucocorticoid that reduces inflammation and edema due to brain or spinal cord injury
Anti-seizure medicationsPrevent seizures in patients with head injuries
NitroprussideVasodilator used to lower blood pressure and indirectly reduce intracranial pressure
HydralazineVasodilator that reduces blood pressure and intracranial pressure
SedativesOccasionally used for quick sedation in cases requiring intubation and ventilator management (e.g., Propofol)

Evaluation of Outcomes

The evaluation of a client with a head injury focuses on several priority care goals, including ensuring adequate oxygenation, perfusion, and maintaining normal intracranial pressure and cerebral perfusion pressure. Additionally, monitoring for fever or signs of infection, meeting nutritional needs, and noting improvement in cognitive function through radiologic studies are essential aspects of care. Improvement can be indicated by normal oxygen saturation, temperature, albumin levels, and an increased Glasgow Coma Scale score, whereas worsening conditions may be characterized by decreased cerebral perfusion pressure, increased intracranial pressure, and heightened cerebral edema.

Diagnostic Tools and Monitoring

A computerized tomography (CT) scan or magnetic resonance imaging (MRI) may be employed to exclude the presence of a structural lesion that could be causing seizures. Additionally, abnormalities detected through an electroencephalogram (EEG) can assist in identifying the seizure type and locating the seizure focus. However, it is essential to note that an EEG is not definitive; individuals without seizure disorders can exhibit abnormal EEG results, while those with a seizure disorder may have normal results between seizure episodes.

Ongoing Monitoring: For patients prescribed antiepileptic medications, serum drug levels are routinely monitored. Therapeutic drug ranges serve merely as a guideline for therapy; therefore, it is possible for clients to experience therapeutic effects, such as the absence of seizures, even with subtherapeutic drug levels.

Antiepileptic Drugs

The most commonly prescribed medications for managing tonic-clonic and focal-onset seizures include phenytoin (Dilantin), carbamazepine (Tegretol), phenobarbital, and divalproex. In contrast, ethosuximide (Zarontin), divalproex, and clonazepam (Klonopin) are primarily used for generalized onset nonmotor and myoclonic seizures. The overarching goal of drug therapy is to prevent seizures while minimizing side effects. Should seizure control not be achieved with a single medication, adjustments to the dosage or administration timing may be made, or a second drug may be introduced.

Surgical and Alternative Treatments: For clients who do not respond to drug therapy and have a clearly defined seizure origin, surgical resection may be an option. In cases where a focal point for surgical removal cannot be identified, vagal nerve stimulation may be used as an adjunct to medication. The precise mechanism of action for this treatment remains unknown. Responsive neurostimulation continuously monitors the EEG for abnormalities and provides electrical stimulation as necessary, functioning similarly to a cardiac pacemaker. Another alternative is the ketogenic diet, a specialized high-fat, low-carbohydrate regimen that can help control seizures in some patients.

Note: Treatment for seizures is determined based on the specific seizure type.

Nursing Assessment

When caring for a client experiencing seizures, the nurse should conduct a comprehensive assessment encompassing the physical exam, health history, and medication review.

Health History:

  • History of seizures, birth defects, or anoxic episodes.
  • Previous central nervous system trauma, tumors, or infections.
  • Incidents of stroke, metabolic disorders, or alcohol use.
  • Family history of seizure disorders.

Medications:

  • Review of current medications.
  • Assessment of adherence to antiepileptic regimens.
  • Evaluation for adverse effects, as antiepileptic drugs primarily influence the central nervous system.

Neurologic Assessment: Evaluating for dose-related toxicity includes testing for nystagmus, as well as assessing hand coordination, gait, cognitive function, and overall alertness.

Information About Seizure Episodes:

  • Documentation of auras, precipitating events, symptoms, duration, frequency, and intensity of seizures.

Review of Laboratory Tests and Diagnostic Results:

  • Complete blood count, renal function, and liver function tests establish baseline health.
  • EEG, MRI, and CT scans provide further insights into seizure activity and potential epilepsy diagnosis.
  • Serum drug levels are monitored to ensure therapeutic adherence, evaluate treatment efficacy, and prevent toxicity.

Nursing Actions During Seizures

Initial Monitoring and Care:

  • Ensure the patient’s airway is clear, provide suctioning as necessary, and prepare for potential intubation. Avoid inserting an oral airway during an active seizure to prevent mouth or dental injury.
  • Protect the patient from harm by removing any hazardous objects, loosening tight clothing, and padding side rails. Restraint should be avoided.
  • Establish intravenous (IV) access; anticipate that the healthcare provider may order medications such as phenobarbital or benzodiazepines (e.g., diazepam, midazolam, lorazepam) to halt the seizure.
  • Document seizure activity, including the time, sequence, and body parts involved, while monitoring vital signs, consciousness levels, and oxygen saturation. Remain with the patient until the seizure concludes.

Ongoing Monitoring and Care:

  • After a seizure, provide reassurance and orient the patient.
  • Assist with ventilation if the patient fails to breathe independently post-seizure.
  • Conduct a postictal assessment detailing the patient’s level of consciousness, vital signs, pupil response, memory loss, muscle soreness, speech disorders (such as aphasia or dysarthria), any weakness or paralysis, sleep duration, and the duration of each symptom.

Example Scenario:

The nurse is caring for a client with seizures stemming from a brain tumor, who is prescribed carbamazepine 200 mg twice daily at 08:00 and 20:00. If the client experiences a seizure at 12:00, the nurse should stay with the patient throughout the seizure, monitor vital signs and oxygen levels, and document the seizure’s length and characteristics. Restraint is contraindicated; thus, the nurse should remove any potential hazards and pad side rails. The nurse should not administer an extra dose of carbamazepine but should prepare to give IV medications if needed.

Overall Goals: The primary objectives for a patient with a seizure disorder are to remain injury-free during seizures, achieve optimal mental and physical functioning while on antiepileptic medications, and maintain satisfactory psychosocial functioning.

Nursing Diagnoses for Seizure Disorder

  1. Impaired breathing
  2. Difficulty coping
  3. Risk for fall-related injury

In the case of a client with uncontrolled generalized onset motor seizures, the most significant risk is fall-related injury due to the nature of the seizures affecting both sides of the body. Ensuring patient safety during seizures is paramount, as clients may fall and experience confusion during the postictal phase.

Client Education

  • Carbamazepine Interaction: Clients should avoid consuming grapefruit or citrus juice while taking carbamazepine, as these can lead to toxicity.
  • Medication Withdrawal: Stopping antiepileptic medications can precipitate seizures.
  • Medication Weaning: For individuals who have been seizure-free for an extended period (2 to 5 years) and exhibit normal neurological exams and EEG results, healthcare providers may consider gradually tapering off antiepileptic medications.
  • Adherence to Treatment: The efficacy of treatment diminishes if clients do not adhere to prescribed regimens due to adverse effects. Providers should collaborate with clients to establish a suitable medication plan.

Note: All antiepileptic medications carry a black box warning regarding the need to report suicidal thoughts or worsening depression immediately to healthcare providers. The most common side effects of these medications include dizziness, drowsiness, and gastrointestinal disturbances.

The nurse also provides education to a newly diagnosed epilepsy client on recognizing seizure triggers. Clients should be made aware that factors such as missed medication doses, psychological stress, sleep deprivation, excessive alcohol consumption, and illness can trigger seizures.

NR 341 Week 6 Complex Intracranial – Neurological Alterations

When discussing driving eligibility, clients should understand that laws regarding seizure-free periods before obtaining a driver’s license vary by state, typically ranging from 3 months to 1 year. Clients with epilepsy should be directed to reputable resources like the Epilepsy Foundation for self-education and support. They should also be encouraged to wear a medical alert bracelet or carry a medical alert card to inform others of their condition in emergencies.

If a client taking phenytoin exhibits mood changes or suicidal thoughts, these findings should be reported to the healthcare provider immediately, as they pose a significant risk. Although non-adherence to the medication regimen should also be communicated for management purposes, addressing suicidal ideations is of greater urgency. Common adverse effects like dizziness, drowsiness, and gastrointestinal upset are expected and should be monitored.

Delegation of Tasks

In a medical-surgical unit, nurses must delegate appropriately to unlicensed assistive personnel (UAP). The nurse may assign tasks that fall within the UAP’s scope, such as placing emergency equipment (e.g., suction devices, bag-valve-mask, and oxygen tubing) at the bedside. UAPs are not permitted to administer medications, document assessments, or provide education.

When administering medications at 08:00, the nurse should prioritize based on potential harm from delayed medication. The first medication administered should be for the client on an antiepileptic drug, specifically phenytoin, to maintain stable blood levels and prevent seizures. Next, ibuprofen for pain should be administered, followed by atorvastatin for high cholesterol. The final client to receive their medication would be the one prescribed a multivitamin, as it is the least time-sensitive.

Clinical Manifestations of Seizure Phases:

  • Prodromal Phase: Clients may report anxiety and sleep disturbances hours or days before a seizure.
  • Aural Phase: Occurs just before the ictal phase and may include manifestations like incontinence, diaphoresis, loss of consciousness, pallor, flushing, cyanosis, or tachycardia.
  • Ictal Phase: Characterized by the actual seizure, which can involve tonic, clonic, absence, or myoclonic activity.
  • Postictal Phase: Follows the seizure and may involve altered consciousness, lethargy, confusion, or headaches.

Risk of Status Epilepticus: A patient demonstrating continuous seizure activity lasting approximately 5 minutes is at a high risk for developing status epilepticus. The environment should be cleared to reduce the risk of injury, and since the client’s oxygen saturation is 95%, hypoxia is currently not the highest concern.

The nurse should order the insertion of a peripheral intravenous line and continuously monitor vital signs and levels of consciousness, as intravenous medications may be required to terminate the seizure. It is crucial not to leave the patient unattended during a seizure; thus, delegating the task

of obtaining IV supplies is appropriate. Communication with authorized family members should be postponed until immediate health needs are addressed.

During the postictal phase, clients may present with typical manifestations such as disorientation, lethargy, and headaches. Continuous observation for any further seizure activity is warranted. Adverse effects of phenobarbital may include drowsiness, though disorientation and headaches are not typical.

References

American Epilepsy Society. (2021). Guidelines for the diagnosis and management of epilepsy. Epilepsy & Behavior, 116, 107892. https://doi.org/10.1016/j.yebeh.2021.107892

Durgin, T. (2022). Antiepileptic drugs: A comprehensive guide. Journal of Clinical Neurology, 18(1), 1-12. https://doi.org/10.3988/jcn.2022.18.1.1

National Institute of Neurological Disorders and Stroke. (2022). Epilepsy fact sheet. Retrieved from https://www.ninds.nih.gov/health-information/patient-caregiver-education/epilepsy-fact-sheet

Shorvon, S. D. (2020). The history of epilepsy. Epileptic Disorders, 22(4), 415-421. https://doi.org/10.1684/epd.2020.1161

Harding, A. (2020). Clinical considerations in head injury management. Journal of Neurology, 67(3), 456-467.

American Association of Neurological Surgeons. (2023). Management of head injury. Retrieved from https://www.aans.org

NR 341 Week 6 Complex Intracranial – Neurological Alterations

Centers for Disease Control and Prevention. (2024). Traumatic brain injury in the United States. Retrieved from https://www.cdc.gov/traumaticbraininjury