Class 6: Neuro & AED Flashcards
Antiepileptic drugs goals of therapy & length
-AKA anticonvulsants
-Control/prevent seizures
-Lifelong therapy, a combination of drugs may be used
AED therapy & what to monitor
-Single-drug therapy is tried first
-Measure phenytoin (dilantin) serum concentrations
AED effect
-Prevent generation and spread of electrical discharge from dysfunctional nerves
-Protect surrounding cells
-Neurons are stabilized
AED MOA
-Exact MOA is unknown
-Thought to alter movement of Na+, K+ and Ca+ ions across nerve cells in the brain to reduce nerve excitability
AED indications
-Long-term therapy of seizures
-Acute tx of convulsions and status epilepticus
Other uses: BPD
Most common first line seizure drugs
-CPPPF
-Carbamazepine, phenobarbital, primidone, phenytoin, & fosphenytoin
-Used for focal, secondary & tonic-clonic seizures
Adjunct seizure drugs
-ACOZ
-Acetazolomide, clonazepine, oxcarbazepine & zonisamide
Clonazepine is used in…
Focal, secondary, tonic-clonic, & myoclonic seizures
First-line & adjunct drugs for focal seizures
-First-line: CPPPF
-Adjunct drugs: Clonazepam, oxcarbazepine, topiramate, gabapentin, clorazepate, pregabalin, lamotrigine, levetiracetam & perampanel
First-line & adjunct drugs for secondary generalized seizures
-First line: CPPPF & lamotrigine
-Adjunct: Clonazepam, oxcarbazepine, topiramate, gabapentin, & levetiracetam
First-line & adjunct drugs for generalized tonic-clonic seizures
-First-line: CPPPF, lamotrigine & valproic acid
-Adjunct: Clonazepine, zonisamide & topiramate
First-line & adjunct drugs for absent seizures
-First-line: Valproic acid & ethosuximide
-Adjunct: Acetazolamide
First-line & adjunct drugs for myoclonic seizures
-First-line: Valproic acid
-Adjunct: Clonazepam
Diazepam IV dose
5-10mg
Diazepam onset, duration & half-life
-Onset: 3-10 min
-Duration: Minutes
-Half-life: 35 hr
Diazepam adverse effects
-Apnea, hypotension & somnolence (sleepy/drowsy) (same as lorazepam)
Fosphenytoin IV dose
15-20 phenytoin equivalents/kg
Fosphenytoin onset, duration & half-life
-Onset: 15-30 min
-Duration: 12-24hr (same as phenytoin)
-Half-life: 10-60hr
Fosphenytoin adverse effects
-Dysrhythmias & hypotension (same as phenytoin)
Lorazepam IV dose
0.05mg/kg (max 4mg)
Lorazepam onset, duration & half-life
-Onset: 1-20 min
-Duration: Hours
-Half-life: 12-15 hr
Lorazepam adverse effects
-Apnea, hypotension & somnolence (same as diazepam)
Phenytoin IV dose (Adults & peds)
-Adults: 150-200mg
-Children: 250mg/m^2
Phenytoin onset, duration & half-life
-Onset: 1-2hr
-Duration: 12-24hr (same as fosphenytoin)
-Half-life: 7-42hr
Phenytoin adverse effects
Dysrhythmias & hypotension
Antiepleptic drug adverse effect
-Often result in the need to change meds
-Narrow therapeutic index
-Monitor plasma levels
Adverse effects of barbiturates: phenobarbital & primidone
Lethargic & restless
Adverse effects of hydantoins: Phenytoin & fosphenytoin
Ataxia, agranulocytosis, rash, nystagmus, gingival hyperplasia, thrombocytopenia & hepatitis
Adverse effects of iminostilbenes: Carbamazepine & oxcarbazepine
aGait, abdominal pain, nausea, headache, unusual eye movement, visual & behavioural change, rash
Adverse effect of valproic acid & derivatives including Na+ & divalproex Na+
GI upset, weight gain, hepatotoxicity & pancreatitis
Gabapentin adverse effects
-Nausea, aVision & speech, edema
Pregabalin adverse effects
Edema & blurred vision
AED contraindications
Pregnancy
AED interactions
-Bone marrow toxicity, CNS depression & breakthrough seizures
-Decreased half-life, aDrug levels
Phenytoin or diphenylhydantoin absorption
-Limited water solubility (not given IM)
-Slow, incomplete & variable absorption
-Extensive binding to plasma
Phenytoin or diphenylhydantoin metabolism
Metabolized by hepatic enzymes via hydroxylation (chance for drug interactions)
Phenytoin or diphenylhydantoin therapeutic concentration & IV considerations
-10-20ug/ml
-If given IV it should only be given in a NS solution
Phenytoin acute toxicity & adverse events high IV & oral OD
-High IV rate can cause arrythmias, hypotension & CNS depression
-Acute PO OD: Cerebellar & vestibular S&S: Nystagmus, ataxia, diplopia & vertigo
Phenytoin chronic toxicity
-Vestibular/cerebellar effects, behavioral changes, gingival hyperplasia, GI disturbances
Sexual & endocrine effects of phenytoin chronic toxicity
Osteomalacia, hirsutism & hyperglycemia
Osteomalacia
Bones become soft & weak
Hirsutism
Condition in women where they grow hair in a male-like pattern
Chronic phenytoin toxicity adverse effects
-Folate deficiency; megaloblastic anemia
-Hypoprothrombinemia & hemorrhage in newborns
-Hypersensitivity reactions
-Pseudolymphoma syndrome; teratrogenic
-FHPH
Hypersensitivity reactions in chronic toxicity effects
SLE, hepatic necrosis, & stevens-johnson syndrome
Stevens-Johnson syndrome
Disorder of the skin & mucous membranes causing blisters and superficial skin cell death
Phenytoin chronic toxicity drug interactions
-Cimetidine & isoniazid decrease metabolism
-Phenobarbital & other AEDs increase metabolism
-Decreased & increased metabolism r/t competition for protein binding sites
AED nursing implications for assessment
-Health hx, BPMH, liver function tests & CBC
AED nursing implications + PO drugs
-Take w meals to reduce GI upset
-Contact physician for alternatives if NPO
AED nursing implications for IV
-Given slowly
-Monitor VS during administration
-Use NS w phenytoin
AED nursing implications & pt considerations
-Journal response, seizure occurence & description and other AEs
-Med alert bracelet, do not abruptly discontinue
-Do not drive until drug levels stabilize
-Long-term/lifelong therapy that is not a cure
AED implications + monitoring
-Monitor for decreased or absent seizure activity
-aLOC, sensation, vision or mood; sore throat, fever (blood dyscrasia may occur with hydantoins)
Seizure management in pediatrics
-Meds, ketogenic diet, vagal stimulation & surgery
-Tx for status epilepticus
Ketogenic diet + pediatric seizures
-High-fat low carb
-Body uses fat as energy source, state of ketosis ensues
-Half of children on the diet had a >50% reduction in seizure episodes
Osmotic diuretics
-Mannitol (osmitrol); most used osmotic diuretic
-Urea, organic acids & glucose
Osmotic diuretic MOA
-Mostly works in the proximal tubule and descending loop of Henle of the nephron
-Nonabsorbable, producing an osmotic effect
-Pull water into the renal tubules from the surrounding tissues
-Inhibit tubular resorption of water and solutes which produces rapid diuresis
Osmotic diuretic drug effects
-Increase GFR & renal plasma flow; helps prevent kidney damage during AKI
-Reduce ICP or cerebral edema associated with head trauma, reduces intraocular pressure
Osmotic diuretic indications
-Early oliguric phase of AKI, cerebral edema
-Promotes excretion of toxic substances, reduces ICP
-GI irrigant to prepare pts for transurethral surgery
Osmotic diuretic adverse effects
-Convulsions, pulmonary congestion, thrombophlebitis
-Other: Blurred vision, chills, chest pain, fever, headaches, & tachycardia
Osmotic diuretics: Mannitol (osmitrol)
-IV only, use a filter
-Store in warmer, crystallizes in low temperatures
Neurological disorders
-Tumors
-Guillian Barre Syndrome
-Hematoma & hydrocephalus
-MS & myasthenia gravis
-Infections – Brain abscess, meningitis & encephalitis
-Parkinson’s disease
Neurological disorders cont’d
-Headaches, seizures, spinal Injuries, ischemic & hemorrhagic strokes
-Carotid endarterectomy
-Intervertebral disc injury
Neurological disorder comorbidities
Cardiac, diabetes & COPD
Medical considerations of neurological disorders & stroke
-Repositioning
-Medications for cardiac, diabetes & other comorbidities
Rehabilitation for neurological disorders & strokes
-PT, OT, & SLP
Tests for neurological disorders & strokes
MRI, CT, D-Dimer (fibrinolysis resulting protein fragment)
Surgical considerations for neurological disorders & stroke
-Surgical and aseptic technique critical
-Assessment and VS q15, 30, 1h x 4, 4h x4, & 8, infection and pain (5th vital sign)
-TED stockings, I/O monitoring
-Pituitary tumor, specific gravity urine testing re: Diabetes
Neurological disorders & stroke considerations for nutrition
-NPO until SLP follows (has implications if your patient is diabetic)
-Watch for aspiration if pt has dysphagia, tube feeding may be required
-Watch for bowel obstruction
Pyschosocial & family considerations for neurological disorders
-Depression common in most neurological disorders
-Great need for re-assurance and support for family – DNR orders
Issues: Powerlessness, loss
Causes of IICP
-Aneurysm rupture & subarachnoid hemorrhage, meningitis
-Brain tumor, encephalitis, head trauma, hydrocephalus, hypertensive brain hemorrhage, Subdural hemorrhage
-Status epilepticus, stroke
Signs of IICP
-Headache, double vision, pupils unresponsive to light, N/V, aMental abilities, loss of conciousness, coma
-Confusion about time then location then people as the pressure worsens
-Separating sutures in infants, seizures, shallow breathing, increased BP
IICP goals of care… Literally
-Maintain patent airway
-ICP within normal limits
-Normal fluid & electrolyte balance
-No secondary complications of immobility and decreased LOC
IICP acute interventions
-Airway protection, adequate oxygenation (monitor PaO2 & PaCO2)
-Maintain SBP
-CPP = MAP – ICP (> 60 mm Hg); mannitol & hypertonic saline
IICP acute intervention medications
AED, sedation & analgesic
IICP acute intervention labs
Glucose & Na+: Prevent hyponatremia as it can mimic IICP
Additional medications used to manage IICP
-AEDs, antipyretics & corticosteroids
-Histamine H2; receptor antagonists
-Stool softeners
IICP acute interventions cont’d
-Head midline, SF= 30 degree, quiet & calm environment
-Nutritional therapy
-Prevent hyperthermia
-Pain assessment unconscious patient & pediatric considerations
Hydrocephalus
-Imbalance in the production and absorption of CSF causing ventriculomegaly
Hydrocephalus tx goals
-Relief of hydrocephalus, promote psychomotor development
-Treat complications
Hydrocephalus tx
-Tx: Remove obstruction or place a shunt
-A ventriculoperitoneal (VP) shunt drains CSF
Complications of VP shunts
Infection or malfunction
Head injury nursing diagnosis + perfusion
Risk for ineffective cerebral tissue perfusion r/t interruption of CBF associated with cerebral hemorrhage, hematoma, and edema
Head injury nursing diagnosis + hyperthermia
Hyperthermia r/t increased metabolism, infection, and loss of cerebral integrative function s/t possible hypothalamic injury
Head injury nursing diagnosis + acute pain
Acute pain (headache) r/t trauma and cerebral edema
Head injury nursing diagnosis + mobility
Impaired physical mobility r/t decreased LOC, impaired motor responses, and uncertain future
Head injury nursing diagnosis + anxiety
Anxiety r/t abrupt change in health status, hospital environment, and uncertain future
Potential complications of head injuries
IICP r/t cerebral edema and hemorrhage
Head injury goals of care
-Maintain cerebral perfusion & temp
-Attain maximal cognitive, motor, and sensory function
Head injury management
-Prevention of secondary injury r/t cerebral edema and IICP
-Craniotomy or burr-hole
Emergency care of head injuries
-ABC, C-spine, O2 via NP or NRM
-Establish 2 large bore IVs, control external bleeding
-Asses for rhinorrhea, otorrhea, scalp wounds
-Remove clothing
Ongoing monitoring of head injuries
-Administer fluids cautiously, anticipate need for intubation
-Maintain temp
-Monitor S&S of IICP or decreased ICP
-V/S & neuro V/S, LOC, GCS, O2, rhythm
Primary prevention strategy of head injury
Health Promotion
Drug therapy for nursing implementations
Antiemetic’s & headache medication
NANDA for acute meningitis
-Risk for ineffective cerebral perfusion
-Acute pain
-Hyperthermia
-Seizure activity
Management of acute meningitis
-Isolation, I&O/fluid balance
-LOC/ICP, VS/NVS
-Seizure prevention/precaution
Stroke “brain attack” cause & types
-Injury to part of the brain from lack of blood flow
-Two Types: Ischemic & hemorrhagic
Ischemic stroke types
-Thrombotic; blood clot forms within the arteries
-Embolic; plaque fragment or blood clot travels to the brain from the heart or another artery
Tx of strokes
-Antiplatelet & antithrombotic therapy:
-tPA (tissue plasminogen activator), coumadin
-Heparin infusion/sc inj, aspirin
-Plavix (Clopidogrel)
Nursing management of ischemic strokes
-NVS including GCS & NIHSS
-Monitor for IICP, cerebral edema or ICH
-HTN is common: BP parameters
HTN drug management post ischemic stroke
-Labetolol IV push
-Captopril
Post ischemic stroke monitoring
-Observe for cardiac abnormalities, TED stockings
-O2, maintain airway, intubation supplies
-Observe for changes in patient deficits: Hemiplegia, neglect, facial droop, aVision, memory, speech (aphasia)
Nursing management of ischemic strokes: Family
-Emotional support and reassurance to both the patient and the family
-Loss: Loss of the person they once knew, function & role shifts
Hemorrhagic stroke types
-Intracerebral hemorrhage; spontaneous hemorrhage r/t HTN
-Subarachnoid hemorrhage; bleeding into the subarachnoid space, commonly r/t ruptured aneurysm
Tx of hemorrhagic stroke
-Damage control caused by bleed
-Poor prognosis (coma)
-Manage BP & IICP
Nursing management of hemorrhagic stroke + family
-GOC discussion
-Emotional support and reassurance early with patients and families is essential
Nursing management of hemorrhagic is the same as ischemic except…
-Monitor BP, and keep BP between set parameters to limit/prevent re-bleed
-Monitor for IICP
-May require a EVD (external ventricular drain)
External Ventricular Drain (EVD)
-Drains CSF to decrease ICP
-Closed system, easily contaminated
Surgical management of an aneurysm
Clipping, endovascular coiling, or flow diverters
Triple H therapy of nursing management
-HTN (Labetalol, Hydralazine, Nimodipine)
-Hypervolemia (ICP care, goal euvolemia)
-Hemodilution (prevent and treat cerebral vasospasm)
