Chapter 44: Care Of Patients With Priblems Of The CNS: Brain Flashcards
Migraine headache
Typical migraine is described as unilateral, fronto-temporal, throbbing pain in the head that is often worse behind one eye or ear, often accompanied by a sensitive scalp, anorexia, photophobia (sensitivity to light and noise), and nausea with or without
A Migraine headache—chronic, episodic disorder with multiple subtypes
Classified as a long-duration headache because it usually lasts longer than 4 hours
Medication for migraines
Abortive therapy—alleviating pain during the early aura phase or soon after the headache has started:
ØDrug therapy to manage migraine HA’s
•Mild HA’s nonspecific analgesics Acetaminophen
•Mild HA’s nonsteroidal anti-inflammatory (NSAIDs) Ibuprofen or Naproxen, beta blockers Propranolol or Timolol
•Severe HA’s ergotamine preparations Cafergot, triptan preparataions Imitrex, isometheptene combinatiaon Midrin and antiepileptic drugs Epakote
•Triptan preparations such as Imitrex instruct patients to report chest pain or tightness immediately. They may also cause rebound HA
•Contraindicated in patients with actual or suspected ischemic heart disease, cerebrovascular ischemia, hypertension, peripheral vascular disease and those with Prinzmetal’s angina due to potential coronary vascular spasm
Preventive therapy: when migraine HA’s occur more than 2x/week, interfere with ADLs or not relieved with acute treatment
Interventions for migraine
The 3 R’s (National Headache Foundation):
ØRecognize migraine symptoms
ØRespond and see health care provider
ØRelieve pain and associated symptoms
The priority for care of the patient having migraines is pain management
Cluster headache
Cluster HA’s are manifested by brief intense unilateral pain that generally occurs in the spring and fall.
It is the most common chronic short-term HA with pain lasting less than 4 hours.
Men are affected 3-4 times more than women.
Histamine cephalalgia less common than migraines.
Cause unknown; attributed to vasoreactivity and oxyhemoglobin desaturation.
Unilateral, radiating to forehead, temple, or cheek, NONthrobbing
Ipsilateral tearing of the eye, rhinorrhea, ptosis, and miosis (pupil constriction)
They occur at the same time every day for about 4 to 12 weeks which is why they’re called cluster. You may have a period of remission for nine months afterwards.
Cluster headache treatment
Same types of drugs used for migraines
Patient to wear sunglasses and avoid sunlight
Oxygen via mask 7-10L for 15-30min
Avoidance of precipitating factors, such as anger, excitement
Surgical management if drug resistant
CAM for migraines
Yoga, meditation, massage, exercise, biofeedback, relaxation techniques
Acupuncture, use of herbs and nutritional therapies with approval
ØTriptan drugs should not be taken with selective serotonin reuptake inhibitor (SSRI) antidepressants or St. John’s wort, an herb used commonly for depression.
Avoidance of trigger events that may result in migraine episodes, such as tension and stress
Recommend at beginning of a migraine HA to reduce pain by lying down and darkening the room. Close or cover eyes and apply cool cloth to forehead.
If patient falls asleep, he/she should remain undisturbed until awakening.
Instruct patient to take preventive drugs regularly, avoid triggers and use complimentary alternative therapies to help them relax and avoid HA.
Emphasize a healthy lifestyle and avoid smoking, exercise regularly, eat a balanced diet, and get adequate rest and sleep.
Tension headache treatment
Tension HA’s are the most common type of chronic long-duration HA lasting more than 4 hours
Neck and shoulder muscle tenderness and bilateral pain at the base of the skull and in the forehead
Head pain without associated symptoms
Treatment—non-opioid analgesics, muscle relaxants, occasional opioids
Ibuprofen plus caffeine
Prophylactic treatment similar to that used in treating migraine headaches
Health teaching aides:
Lifestyle changes to include routine sleeping pattern, exercise, massage, yoga to reduce stress, and a healthy diet to include fruits and vegetables and to avoid fasting and triggers for headaches that include caffeine, smoking, pickled foods, and red wine.
Peppermint oil may halp
Seizure
Seizure—abnormal, sudden, excessive, uncontrolled electrical discharge of neurons within the brain; may result in alteration in consciousness, motor or sensory ability, and/or behavior
Secondary seizures—result from an underlying brain lesion, most commonly a tumor or trauma
Tension headaches
Tension HA’s are the most common type of chronic long-duration HA lasting more than 4 hours
Neck and shoulder muscle tenderness and bilateral pain at the base of the skull and in the forehead
Head pain without associated symptoms
Tonic-clonic seizure
Generalized seizures occur and involve both cerebral hemisipheres. There are 6 types and will discuss 2 types:
ØTonic-clonic last 2-5 minutes. Tonic phase is stiffening and rigidity of muscles and immediate loss of consciousness (LOC). Clonic is a rhythmic jerking of all extremities follows the tonic phase. May bite tongue, incontinent of urine or feces. Fatigue, confusion, and lethargy may last up to an hour after the seizure. Refer to Memory Notebook Vol. 2, 4th Ed, p. 130
Absence seizure
ØAbsence seizure common in children with LOC and blank staring may last for a few seconds with automatisms (involuntary behaviors) such as lip smacking and picking at clothes
Epilepsy
Epilepsy— defined by the National Institute of Neurological Disorders and Stroke as “two or more seizures experienced by a person”; chronic disorder with recurrent, unprovoked seizure activity, may be caused by abnormality in electrical neuronal activity and/or imbalance of neurotransmitters (e.g., GABA)
Primary or idiopathic epilepsy is not associated with any identifiable brain lesion or other specific cause.
Seizure treatment with meds
Antiepileptic drugs (AEDs)
ØBe aware of drug-drug and drug-food interactions. Instruct patient to avoid drugs and foods that might interfere with the absorption or metabolism of the AED. For instance warfarin (Coumadin, Warfilone) should not be given with phenytoin (Dilantin)
Importance of compliance
ØTeach and emphasize patients to take their drugs on time and not to miss a dose to maintain therapeutic blood levels and maximum effectiveness
Health teaching
ØEmphasize that AEDs must not be stopped even if the seizures have stopped can lead to life threatening complication of status epilepticus
ØTeach importance of having serum drug levels monitored to ensure a therapeutic level, and assess for high levels that could indicate toxicity
Seizure precautions
Precautions are taken to prevent the patient from injury if a seizure occurs. Have to following:
Oxygen
Suction equipment
Airway
IV access, insert saline lock
Siderails up: Should be up and side rails are rarely the source of significant injury, follow hospital policy about use of side rails because now classified at a restraint
No tongue blades: padded tongue blades do not belong at the bedside and should NEVER be inserted into the patient’s mouth because the jaw may clench down as soon as the seizure begins. Forcing a tongue blade or airway into the mouth is more likely to chip the teeth and increase the risk of aspirating tooth fragments than prevent the patient from biting the tongue. Furthermore, improper placement of a padded tongue blade can obstruct the airway
Risk for seizure
Seizures may result from:
ØMetabolic disorders
ØAcute alcohol withdrawal
ØElectrolyte disturbances. Such as
hyperkalemia, water intoxication, and
hypoglycemia
ØHeart disease
ØHigh fever
ØStroke
ØSubstance abuse
These are not considered epilepsy. Increased physical activity, emotional stress, excessive fatigue, alcohol, caffeine, foods or chemical can trigger a seizure
Acute seizure management
Lorazepam (Ativan)
Diazepam (Valium)
Diastat (Diazepam rectal gel)
IV phenytoin (Dilantin) or fosphenytoin (Cerebrex) causes fewer cardiac problems than Dilantin and can be given in an IV dextrose solution
Status epilepticus
Medical emergency!
Prolonged seizures lasting more than 5 minutes or repeated seizures over the course of 30 minutes
It is a potential complication of all types of seizures!
Seizures lasting longer than 10 minutes can cause death!
Common causes: sudden withdrawal from AED’s, infections, acute alcohol or drug withdrawal, head trauma, cerebra edema, metabolic disturbances
Establish an airway is the top priority! Intubation by respiratory therapy (RT) or anesthesia may be necessary
ABGs
IV push drugs of choice lorazepam (Ativan), diazepam (Valium); rectal diazepam gel (Diastat)
Loading dose IV phenytoin to prevent additional tonic-clonic seizures or cardiac arrest
Seizure management
Precautions are taken to prevent the patient from injury if a seizure occurs. Have to following:
Oxygen
Suction equipment
Airway
IV access
Siderails up: Should be up and side rails are rarely the source of significant injury, follow hospital policy about use of side rails because now classified at a restraint
No tongue blades: padded tongue blades do not belong at the bedside and should NEVER be inserted into the patient’s mouth because the jaw may clench down as soon as the seizure begins. Forcing a tongue blade or airway into the mouth is more likely to chip the teeth and increase the risk of aspirating tooth fragments than prevent the patient from biting the tongue. Furthermore, improper placement of a padded tongue blade can obstruct the airway
Surgical management of seizures
Vagal nerve stimulation (VNS)
Conventional surgical procedures
Anterior temporal lobe resection
Partial corpus callosotomy
Care during a seizure
Protect from injury, do not put anything in mouth, turn to side, loosen restrictive clothing, maintain airway and suction, do not restrain, record the time seizure began and ended.
After take the patient’s vital signs, performed neurological checks, keep patient on side, allow patient to rest, document seizure
Meningitis
Meningitis—inflammation of the meninges that surround the brain and spinal cord
Viral meningitis—usually self-limiting and the patient has a complete recovery
Bacterial meningitis—potentially life-threatening
Regardless of the causative organism, symptoms are the same
The organisms responsible for meningitis enter the CNS via the bloodstream at the blood brain barrier (BBB). Direct routes of entry occur as a result of penetrating trauma, surgical procedures, or a ruptured cerebral abscess. Example, a basilar skull fracture can lead to meningitis as a result of the direct communication of CSF with the environment
Viral meningitis
Most common type
Results from a variety of viral illnesses including measles, mumps, herpes simplex and herpes zoster
No exudate and no organisms are obtained from the CSF.
Clinical manifestation of viral meningitis include fever, photophobia (light sensitivity), headache, myalgias (muscle aches), and nausea.
Bacterial meningitis
A medical emergency with a mortality rate of about 25%.
Occurs most often in the fall and winter when URIs commonly occur
Most frequent involved organism is Streptococcus pneumoniae (pneumococcal disease) and Nisseria meningitidis (meningococcal)
Meningococcal meningitis is the only type of bacterial meningitis that occurs in outbreaks. It is most likely to occur in areas of high population density, such as college dormitories, military barracks, and crowded living areas
The number of outbreaks on college campuses has been declining over the past few years because many states require students to be vaccinated against meningitis.
Teach people who live in highly populated areas the importance of getting the meningitis polysaccharide vaccine to prevent infection by certain groups of meningococcal bacteria.
