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Ketogenic diet? what is it for?
Is a special high fat, low carb diet with special measurements of calories, fluids and proteins.
Usually prescribed by a physician when epilepsy is not responding to seizure medications. Body uses fat as main source of energy and it has been proven to help prevent seizures.
Risk factors for Stroke?
- drinking too much alcohol
- High cholesterol
S&S of stroke
Acute numbness/weakness of arm, face, leg, confusion, dysphasia/aphasia, vision changes and dizziness.
Prevention of strokes?
- eat healthy-decrease saturated fats
- Maintain healthy weight-exercise
- Don't smoke
- limit alcohol use
- Manage other health conditions-diabetes/cholesterol/HTN
Normal range of ICP? and total volume of blood or csf?
- 10-20mm hg
- CSF: 75ml
- Blood: 75ml
Few reasons for increased ICP?
- Increased brain volume: tumors,
- Increased cerebral blood volume: hemorrhage, trauma/hematoma
- Obstruction of CSF outflow: build up of CSF in ventricles-requires a shunt
- Cerebral edema: too much water/low sodium, hypertensive crisis, cytotoxic/hypoxic event may trigger inflammation and lead to further swelling.(meningitis/stroke)
Cushings triad related to acute ICP?
- Brady cardia
- widening pulse pressures Systolic increases/ dystolic decreases.
- Cheynes-stokes respirations
Early S&S of ICP
- Visual changes
- motor weakness
Later S&S of ICP
- decorticate/decerebate posturing
- loss of brain stem reflexes
- Positive Babinski sign: big toe flexes other toes fan out.
Complications of ICP
- Brain stem herniation
- diabetes insipidus-decreased ADH
- SIADH-Too much ADH
Steps of ICP management
- CSF drainage-sedation-chemical paralysis-hyperosmolar therapy
- Hyperventilation PAco2 <35 -hypothermia 33-35 celcius-barbs-decompressive craniotomy
Nursing interventions of ICP
- Assess: pupils, LOC, motor and sensation, respiratory pattern.
- Monitor: ABG
- Maintain: HOB at 15-30 degrees.
- Administer: medications appropriately for condition (mannitol / furosemide)
CO2 and ICP relationships
elevated PaCO2 leads to cerebral vasodilation due to lack of O2 going to brain-this increases cerebral blood flow leading to further ICP.
- Decreased PaCO2 leads to hypocapnoeic Vasoconstriction due to a change in PH. This causes a decrease in blood flow to the brain that decreases ICP, but can cause some cerebral ischemia.
- Intermittent hyperventilation for ICP
Types of stroke?
Ischemic: thrombotic (atherosclerosis) or an embolism
Hemorrhagic: Aneurysum, AVM-arteriovenous malformation, bleeding from injury, HTN, anticoagulant.
- transient ischemic attack- "mini" stroke
- lasts 1-2 hours depending
- Does not cause tissue to die
Medical interventions for ischemic strokes
Fibrinolytic therapy: tPA-tissue plasminogen activator-within 4.5 hours
endovascular interventions: stents, embolectomy, endarterectomy
Nursing care for ischemic stroke
- Monitor for ICP
- maintain BP within acceptable range (140-150 systolic)
- ongoing pharm therapy: anticoagulants, smooth muscle relaxants, calcium channel blocker, antiseizure medications.
arteriovenous malformation (AVM)
congenital absence of capillary networks leading to leakage of blood to surrounding tissue.
- Surgery (microsurgery)
- Radiosurgery (sterotactic radiotherapy) Beams of radiation to choke off blood supply to AVM
- embolization (endovascular surgery) same procedure as diagnostic angiogram-they close one or more of the blood vessels, normally used in conjuction with microsurgery.
- conservative medical management.
Risks for bleeding in hemorrhagic stroke?
- liver disorder with decrease in clotting factors.
Diagnostic tests for stroke?
- CT or CT w/ Angiograph
- bleeding times
- ECG for cardiac issues
Medical interventions for hemorrhagic stroke
- 30-40% chance of death initially
- treated with neurosurgery or neurosurgery with interventional radiology
- Control BP
Nursing care for hemorrhagic stroke
Monitor for ICP, signs of hemorrhage
Provide O2 and post-op care
Behavioral changes of Left hemisphere
- anxiety w/ new tasks
- sense of guilt/ worthleness
Behavioral changes of right hemisphere
- lack of awareness
- consistent smile
- overestimation of abilities
Brocas area of the brain-difficulty speaking or trouble finding words
Wernickes area of the brain-difficulty understanding spoken or written words
Difficulty articulating a sentence: meaningless speech
helps to find blockages in blood vessels of the neck and head. They will inject a contrast dye in order to get a better picture.
Checks for abnormal brain activity-checks brain waves. Mainly used to diagnosis seizure activity.
Computerized tomography (CT) or CAT scan-Computerized axial tomography
Uses x-rays to create cross sections of the body.
Magnetic resonance imaging (MRI)
Uses a magnetic field and pulses of radio wave energy to create images of organs and structures within the body. Gives different information then a CT/x-ray/ ultrasound.
Used to assess the CSF to check for meningitis
- Key differences between Viral and bacterial
- Cloudy appearance vs clear appearance.
- Increased WBC for both
- proteins will be slightly elevated
- Inflammation of the meninges due to viral (herpes, measles, mumps) or bacterial and possible fungal.
- S&S: headache, AMS possible, phonophobia, photophobia, neck stiffness, high fever, N/V, muscle aches.
- Bacterial may have petechiae on trunk or extremities.
- inflammation of the brain tissue: cerebrum, brainstem, cerebellum.
- Usually caused by viruses that travel to the CNS-causing inflammation which leads to neuronal damage.
- similar S&S as meningitis
Multiple sclerosis (MS)
- Degeneration of the myelin sheath of the neurons. autoimmune disease-antibodies attack own myelin.
- Blurred or double vision
- Thinking problems
- Clumsiness or a lack of coordination
- Loss of balance
- Weakness in an arm or leg.
- heat sensitivity
- neuropathic pain
- impaired cognitive ability
Herniated nucleus pulposus
- Gel surrounding the intervertebral disc bulges or herniates through bands of fibrous tissue.
- This leads to compression on spinal nerve roots, vascular structure and spinal cord. leads to pain a neuro symptoms.
HNP risk factors and treatments
- Risk factors: repetitive bending, twisting, lifting, weak abdominal muscles, poor body mechanics.
- Treatments: Bedrest, PT, TENS unit, pain meds, Laminectomy, fusion of unstable vertebrae
Spinal cord injury (SCI)
- Complete and incomplete injury one with complete deficits and the other with partial.
- Can lead to Autonomic dysreflexia-which can lead to uncontrolled HTN-and stroke
Key features of Autonomic dysreflexia
- Severe headche
- flushing above injury
- pale extremities below injury
Primary epileptic seizure
defined as 2 or more seizures, chronic. May be caused by an imbalance of neurotransmitters (GABA)
- commonly the result of tumor or trauma.
- Other examples-alcohol withdrawal, high fever, hypoxia, drug intoxication/poisoning, electrolyte imbalance, hypoglycemia.
Types of seizures
- partial: starts in a specific part of the brain with focal discharges.
- generalized: affects the whole brain from beginning of seizure to end.
Subtypes of partial seizures
- Simple: patient doesn't lose consciousness (myoclonic)
- Complex: patient has impaired consciousness (absence)
Depending on where the partial seizure is located we'll have different S&S
- Temporal: hearing, memory, sound, smell, emotions-emotional changes most common
- Frontal: long-term memory, speech (Brocas), taste-jacksonian march: abnormal movement of hand and it progresses up the arm.
- Parietal: interpret touch, sensation, texture, size, spatial relationships.-tingling of one side of body/warmth
- Occipital: vision-changes or seeing flashing lights.
Complex partial sizures
- impaired consciousness for 1-3 mins (syncope)
- unaware of env; amnesia
- occurs anywhere in brain, but most common in temporal lobe
- characterized by automatisms
Partial seizures can progress to?
A generalized seizure
Subtypes of generalized seizures*
- non-convulsive: absence (petit mal)
- Convulsive: Tonic-clonic (grand mal)
Absence (petit mal)-characteristics
- change in consciouness
- rolling eyes, blank stare, day dreaming, slight mouth movements.
- can have up to 100 a day brain return to normal without issue.
- can progress to tonic clonic
- sudden, brief jerking of muscle groups
- aka: akinetic seizure
Generalized clonic tonic seizure (grand mal) characteristics?
- syncope-with full body tonic phases and clonic phases as the individual experiences muscle spasms.
- cyanosis, tongue biting, apnea, incontinence can occur. lasts up to 5 mins commonly
Complications of seizures
- memory loss
- brain damage if seizure prolonged
- risk for hypoxia, vomiting, aspiration, persistent metabolic disorders
nursing process if your patient seizes
- not time of seizure
- protect head
- maintain airway/O2
- prevent aspiration-lateral recumbent-suction
- use padded rails
- loosen constrictive clothing
- blood draws and check BG/temp.
Postictal phase after tonic clonic
effects after the seizure-confusion, drowsy, fatigued, muscle pain, weakness, headache. takes mins-hours to regain consciouness
Common medications for seizures
can they cure seizure?
- no they're ment to control 50-60% efficacy.
- 20-35% of patients with seizure do not get relief from seizures.
Toxicity S&S of phenytoin, phenobarbital and gabapentin
phenytoin: nystagmus, ataxia, confusion, nausea, slurred speech and dizziness
phenobabital: confusion, drowsiness, dyspnea, slurred speech, staggering
Gabapentin: confusion, depression, ataxia, drowsiness, altered reflexes, paraesthesia.
Other interventions for seizure control?
- Vagus nerve stimulation
- lobectomy-surgical resection of seizure area in brain
- corpus callostomy: surgeon sections anterior 2/3 of corpus callosum to prevent neuronal discharge.
- degeneration of dopamine receptors in the brain called substantia nigra where dopamine is created. This leads to less dopamine in the brain.
- dyskinesia, dysphagia, unsteady gait, whole body fatigue, impaired speech, tremors, shakiness.
- nursing diagnosis