What is Electroencephalography (EEG)?
It represents the record of the Electrical Activity generated in the brain
electrodes are placed in the scalp
What is EEG useful for?
- 1. Diagnosing and evaluating seizure disorders
- 2. coma
- 3. organic brain syndrome
- 4. tumors
- 5. brain abscesses
- 6. blood clots
- 7. infection in the brain
- 8. brain death
- pt lies quietly with both eyes closed
- asked to hyperventilate fir 3-4 mins
- or to look at a bright, flashing light
- Why to look at lights?
- to evoke abnormal electrical discharge (seizure potentials)
What is Sleep EEG?
it is recorded after sedation
what are the nursing implications for EEG
- 1. Pt deprived of sleep the night before EEG
- 2. Anti-seizure, tranquilizers, stimulants & depressents w/held 24 hrs prior
- 3. no coffee, tea, chocolate, colas
- 4. meal is given
- 5. procedure takes 45-60 mins
What is cerebral concussion (mild TBI)?
- a temporary loss of neurologic fn with no apparent structural damage to the brain.
- may or may not cause a brief loss of consciousness
What is the mechanism of concussion?
- 1. Blunt trauma - from an acceleration-deceleration
- 2. a direct blow
- 3. a blast injury
What happens when the temporal lobe is involved with concussion?
temporary amnesia or disorientation
What happens when the frontal lobe is involved with concussion?
it produces bizzare, irrational behavior from the pt
What are the 2 types of concussion?
How long does a mild concussion last?
less than 30 minutes
What are the S/S of mild concussion?
- 1. Seizures
- 2. headache
- 3. Dizziness
- 4. irritability
- 5. fatigue
- 6. poor concentration
*there is usually a memory lapse at time of injury
What can a mild concussion lead to?
- 1. a period of observed or self-reported transient confusion
- 2. disorientation
- 3. impaired consciousness
What is a Classic concussion?
injury that results in a loss of conscioussness that lasts less than 6 hrs with post traumatic amnesia.
What are the S/S of classic concussion?
- 1. headache
- 2. dizziness
- 3. lethargy
- 4. irritability
- 5. emotional lability
- 6. fatigue
- 7. poor concentration
- postconcussion syndrome S/S
- 1. decreased attention span
- 2. memory difficulties
- 3. intelectual dysfunction
What is a seizure?
episodes of abnormal motor, sensory, autonomic, or psychic activity that result from sudden excessive discharge from cerebral neurons
What causes seizures?
- 1. an electrical disturbance (dysrhythmia) in the nerve cells in one section of the brain
- 2. these cells emit abnormal, recurring, uncontrolled electrical discharges
- 3. excessive neuronal discharge
What are the types of seizures?
- 1. simple-partial seizure (beginning locally)
- 2. complex-partial seizure (1 part of the brain)
- 3. generalized seizure (entire brain)
What is a simple-partial seizure?
- begins in one part of the brain
- consciousness remains intact with
- 1. motor symptoms
- 2. sensory/somatosensory symptoms
- 3. autonomic symptoms (loss of bladder/bowels)
- 4. compound forms
What is a complex-partial seizure?
- impairment of consciousness only
- 1. cognitive symptoms
- 2. affective symptoms
- 3. psychosensory symptoms
- 4. psychomotor symptoms
- 5. compound forms
What is a generalized seizure?
convulsive or non-convulsive bilaterally symmetric without local onset
- 1. tonic-clonic seizures
- 2. tonic seuzires
- 3. clonic seizures
- 4. absence (petit mal) seizures
- 5. atonic seizures
- 6. myoclonic seizures
- 7. unclassified seizures
what are the Nursing implications during a seizure?
**observe & record the sequence of signs**
- 1. circumstances before the seizure
- a) visual stimuli
- b) auditory/olfactory stimuli
- c) tactile stimuli
- d) emotional/psychological disturbances
- e) hyperventilation
- 2. occurance of an aura (warning or sensation before seizure)
- 3. 1st thing patient does in the seizure
- 4. types of movement in the part of the body involved
- 5. areas of the body inolved
- 6. both size of pupils (are eyes open or closed?)
- 7. do the eyes or head turn to one side?
- 8. automations? (involuntary activity like lip smacking
- 9. incontinence, how long seizure is
- 10. unconsciousness - duration
Preventing an injury during a seizure
- 1. ease patient to the floor
- 2. protect the head
- 3. loosen clothing
- 4. remove pillows & raise side rails of bed (3 rails only)
- 5. don't try & pry open jaws that are clenched
- 6. don't restrain patient
- 7. place pt on side w/ head flexed forward to prevent aspiration (bed in low position)
After the seizure
- 1. document events leading to & occuring during & after
- 2. prevention of complication like injury and aspiration
- 3. let pt sleep if wanted
What is epilepsy?
- group of syndromes characterized by unprovoked, recurring seizures
- most common - generalized & partial-onset seizures
idiopathic (unknown cause)
epilepsy is a symptom of another underlying condition - brain tumor
What is the pathophysiology of epilepsy?
- unwanted discharges (neuronal) - body may perform erratically
- *if these uncontrolled, abnormal discharges occur repeatedly, a person has epileptic syndrome
What are the manifestations of epilepsy?
- 1. Simple-partial seizure
- 2. Complex-partial seizure
- 3. Generalized seizure
What is simple-partial seizure?
- only a hand may shake
- mouth may jerk uncontrollably
- person may talk unintelligibly
- may be dizzy or
- may experience unusual sights, smells, sounds or tastes
What is complex-partial seizures?
- either remains motionless or moves automatically bu inappropriately
- may experience excessive emotions of fear, anger.
*pt doesn't remember episode at all*
What is generalized seizure?
- 1. involves both hemispheres of the brain - causing both sides of body to react
- 2. intense rigidity of the entire body followed by alternating muscle relaxation & contraction
- 3.tongue is chewed, incontinent of urine & feces
- 4. pt then lies in a deep coma - breathes noisily w/ abd breathing
- *After seizure
- pt is hard to arise & may sleep for hrs
- may have headache, sore muscles, fatigue, & depression
What is epileptic cry?
contracting of diaphragm & chest muscles together
What are the assessments and diagnostics for epilepsy?
- MRI - used to detect structural lesions (location of seizure)
- EEG - assissts in classifying type of seizures and monitors electrical brain activity (type of seizure)
Epilepsy in women
- inc. in seizures during their periods
- contraceptives are reduced by antiseizure meds
- change in pattern of seizures during pregnancy
- low bone mass - associated w/ anti-seizure meds
Seizures in the elderly
- high incidence of new onset
- why? - cerebrovascular disease (leading cause of seizures in elderly)
*meds may be too expensive - low adherence to prescribed regimen
How to prevent seizures (epilepsy)?
Avoid head injury - wear helmets, seat belts
Medical management for epilepsy
medications objective - to achieve seizure control w/ minimal side effects
*meds control they don't cure epilepsy
*start w/ 1 med - adjust med according to concurrent illness, weight changes, or stress
What are the side effects of anti-seizure meds?
- 1. idiosyncratic or allergic d/o - manifest mainly in skin reactions
- 2. acute toxicity - usually occurs when med is 1st prescribed
- 3. chronic toxicity - occurs late in tx
What are the assessment with epilepsy?
- seizure hx
- factors/events that precipitate seizures
- alcohol intake
- aura w/ seizure?
What are the diagnoses for epilepsy?
- risk for injury
- fear r/t seizure activity
- ineffective coping
What are the Interventions w/ epilepsy?
- 1. Prevent injury - side rails x3, pads on side rails
- 2. reduce fear
- a) stick to prescribed meds
- b) avoid stimulants (caffeine, sleep deprivation), no alcohol
- c) moderate exercise
- d) ketogenic diet (high protein, high fat, low carbs)
- e) avoid flickering lights, tv, wear dark glasses outside
What is status epilepticus?
- it is a complication of epilepsy
- acute prolonged seizure activity
- a series of generalized seizures that occur without full recovery of consciousness between attacks
Why is status epilepticus a medical emergency?
because it can cause respiratory arrest and extreme hypoxia to the brain
What causes status epilepticus?
- withdrawal of antiseizure meds
- concurrent infections
What are the medical management for status epilepticus?
- 1. stop seizure
- 2. oxygen to the brain
- 3. maintain a seizure-free pt
- *IV valium is adm slowly to halt seizures
- *IV dextrose if seizure is caused by hypoglycemia
What are the nursing implications for status epilepticus?
- monitor/document seizure activity
- side lying position
- IV line
- protect from injury (seizure precautions)
- protect nurses/doctors from harm
What is ischemic stroke?
sudden loss of fn resulting from disruption of blood supply to a part of the brain
3 hr window for thrombolytic therapy (tPA) - fewer stroke symptoms & less loss of fn
What is the pathophysiology of ischemic stroke?
disruption of the cerebral blood flow d/t obstruction of a blood vessel
cerebral blood flow less than 25ml --> causing ischemia --> acidosis --> intracellular calcium increase --> cells break down (free radicals, protein dec.) --> cells die.
cerebral blood flow less than 25 ml --> causing ischemia --> ion imbalance --> depolarization --> cells break down and die
What are the manifestations of ischemic stroke?
depends on location of obstruction (which vessels are obstructed)
What are the S/S of ischemic stroke
- 1. numbness/weakness of face, arm, or leg (usually one-sided)
- 2. confusion/change in mental status
- 3. trouble speaking or understanding speech
- 4. visual problems
- 5. diff. walking, dizziness, or loss of balance or coordination
- 6. *sudden severe headache
- 7. motor loss
- 8. communication loss (language & communication)
- 9. perceptual disturbances
- 10. sensory loss
- 11. cognitive impairment & psychological effects
Motor loss in stroke (cont'd S/S)
stroke in upper motor neuron lesion results in loss of voluntary control over movements
*Rt sided stroke -> left side loss of control (vice-versa)
Examples of motor dysfunction in stroke
- hemiplegia - paralysis of one side of body (most common)
- hemiparesis - weakness of one of body
What are the common communication losses in stroke?
- 1. dysarthria - diff speaking caused by paralysis of muscle responsible for producing speech
- 2. dysphasia - impaired speech
- 3. aphasia - loss of speech (stroke is the most common cause)
- 4. expressive aphasia - unable to form words that are understandable. can speak in single - word responses
- 5. receptive aphasia - unable to comprehend the spoken word. can speak but doesn't make sense
- 6. global (mixed) aphasia - combo of receptive & expressive aphasia
- 7. apraxia - inability to perform a previously learned action
What is hemianopsia?
- loss of half of the visual field
- can be temporary or permanent
*affected side of vision corresponds to paralyzed side of the body
What is agnosias?
deficits in the ability to recognize previously familiar objects perceived by one or more of the senses
What happens when there's a damage to frontal lobe?
- may impair
- 1. learning capacity
- 2. memory
- 3. higher intellectual fns
ex: limited attention span, diff comprehend, forgetfulness, & lack of motivation
What are the assessments/diagnostics for ischemic strokes?
- 1. airway patency
- 2. cardiovascular status
- 3. neurologic deficits
What is a transient ischemic attack (TIA)?
small strokes - lasting less than 1 hour
What are the manifestations of TIA
- 1. sudden loss of motor
- 2. sudden loss of sensory
- 3. sudden loss of visual fn
TIA may serve as a waring of impending stroke
- CT scan - initial test to see if ischemic or hemorrhagic
- 12-lead carotid ultrasound, and electrocardiogram
How to prevent ischemic stroke?
- Primary prevention - best approach for prevention
- modifiable1. no smoking
- 2. healthy weight
- 3. healthy diet
- 4. modest alcohol consumption
- 5. lose-dose aspirin
- 6. controlling htn
- 7. lowering cholesterol
- non-modifiableage 1. age - 55 yrs and up
- 2. gender - men
- 3. race - african american
What are the medications for stroke?
- 1. coumadin
- 2. statin drugs
- 3. plavix & aspirin (anti-platelets)
- 4. anti-hypertensive drugs (ACE inhibitors)
- 5. thiazides
What is thrombolytic therapy?
it works by dissolving the blood clot that is blocking blood flow to the brain.
t-PA binds to fibrin & converts plasminogen to plasmin which stimulates fibrinolysis of the plaque
Rapid diagnosis & adm of t-PA w/in 3 hrs
- leads to decreased size of stroke
- overall improvement in outcome after 3 months
Why does delays (after 3 hrs) make patient ineligible for t-PA?
bec revascularization of necrotic tissue increases risk of cerebral edema and hemorrhage
criteria for t-PA eligibility
- 18 yrs old and up
- ischemic stroke
- less than 3 hrs of stroke
- no seizure w/ stroke
- not on coumadin
- no heparin
- no intracranial hemorrhage
- no major sx 14 days prior to stroke
- no previous stroke, head injury, brain sx in 3 mos
- no GI or urinary bleeding w/in 21 days
What are the contraindications with t-PA?
- symptom onset > 3 hrs
- anticoagulated pt (INR > 1.7
- previous stroke, head injury, or trauma
- hx of DVTs - bleeding
Maximum t-PA dose?
max is 90 mg a dose
- 10% given as IV bolus over 1 min
- 90% administered in 1 hr
What are the side effects of t-PA?
- intracranial bleeding
What is carotid endarterectomy
it is a surgical prevention for ischemic stroke
-removal of an atherosclerotic plaque or thrombus from carotid artery to prevet strokes in pts w/ occlusive disease of the extracranial cerebral arteries
How long does acute ischemic stroke last?
What are the nursing assessments for acute phase
- 1. change in LOC or responsiveness
- 2. presence/absence of voluntary or involuntary movements of the extremities, muscle tone, body posture & position of the head
- 3. stiffness/flaccidity of the neck
- 4. eye opening - size of pupils, reactive/non reactive
- 5. color of face & skin; temp of skin
- 6. pulse, resp, blood gases
- 7. ability to speak
- 8. I&Os
- 9. bleeding
- 10. BP
What are the interventions?
improve mobility & prevent joint deformities because arm tends to adduct & rotate internally. shoulder tends to adduct.
How to prevent shoulder adduction?
place pillows on axilla - keeps arm away from chest
How to position the hand & fingers?
- positioned so they are barely flexed
- placed in slight supination
What not to use when upper extremities are spastic?
don't use hand roll bec it stimulates the grasp reflex
- every 2 hrs
- may turn side to side but limit time on affected side
- prone position 15-30 mins 2x a day.
why? helps promote hyperextension of the hip & drain bronchial secretions