Chapter 24

Care of Patients with Disorders of the Brain

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Theory Objectives
Describe the appropriate nursing actions and observations to be carried out for a patient experiencing a seizure. Explain why seizure may be a consequence of a stroke, tumor, or infection in the brain. Compare the subjective and objective findings of thrombotic stroke and intercerebral bleed.
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Theory Objectives (cont.)

Devise a nursing care plan for the patient who has suffered a cerebrovascular accident (CVA, stroke). Discuss nursing actions to assist the patient who has developed a complication after a cerebrovascular accident. Describe subjective and objective findings indicative of a brain tumor.
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Theory Objectives (cont.)

Explain the pathophysiology behind the symptoms of a brain tumor. Diagram the mechanism by which infection in the brain may cause increased intracranial pressure. Recall the signs of increasing intracranial pressure from early to late signs.

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Theory Objectives (cont.)

Compare and contrast symptoms of meningitis and encephalitis. Explain the assessment data that differentiate migraine headaches from cluster headaches. Compare the signs, symptoms, and treatment of trigeminal neuralgia and Bells palsy.
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Clinical Practice Objectives

Teach a teenage patient recently diagnosed with epilepsy what he needs to know about his disorder and care. Perform neurologic checks on a patient who is admitted with a suspected CVA. Assist with the care of a patient who has had intracranial surgery. Devise a teaching plan for the patient who has suffered a CVA and has right-sided hemiplegia.
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Seizure Disorders and Epilepsy

Etiology
Brain injury, tumor, infection with high fever, ESRD with uremia, eclampsia, drug poisoning, epilepsy, tetanus, hypoxia, ETOH withdrawal, metabolic disturbances, genetic defects, increases in 60-80 yrs old, 4-8/1000 in US

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Seizure Disorders and Epilepsy

Pathophysiology
Chronic disturbance of nervous system Recurrent spontaneous seizures Unknown stimulus cause cell membranes to depolarizeabnormal sensory or motor activity may lead to unconciousness Neurons have low threshold for excitationspreads to surrounding cells in brain
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Partial Seizures
Signs and symptoms
Partial seizures also are called simple or focal seizures and result from an abnormal localized cortical discharge. Partial seizures with complex symptomatology may also be called temporal lobe seizures because they usually originate in the temporal lobe of the brain. Partial seizures can be unilateral, with involvement on only one side of the brain and activity only on one side of the body.

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Seizure Disorders and Epilepsy

Signs and symptoms
Partial seizures Consciousness not impaired Motor, sensory, autonomic, psychological symptoms Complex partial seizures-some impairment of consciousness, automatisms (lipsmacking etc), may become generalized

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Seizure Disorders and Epilepsy

Generalized seizures
bilateral, symmetrical, no local onset Absence, myoclonic, clonic, tonic, tonic-clonic, atonic, infantile spasms (d/t fever) Electrical discharges in brain (bilateral, synchronous), whole brain affected No warning or aura Loss of consciousness lasting seconds to several minutes Absence or petit malfew seconds, no aura, no post-ictal symptoms, 5-12 yrs disappear in puberty
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Generalized Seizures
Absence-lapse Myoclonic-jerking, twitching of muscle Clonic-rhythmic jerking, loss of conciousness Tonic-continued contraction of muscles Tonic-clonic-jerking/contracting, starts focal, bilateral, grand mal, loss of conciousness Atonic seizures loss of muscle tone, nod head, weak knees Infantile spasms (usually caused by increased temperature)
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Status Epilepticus
Prolonged partial or generalized seizure without recovery between attacks Rapid, unrelenting series of convulsive seizures without intervening periods of consciousness, and an absence of respiration Irreversible brain damage can occur if the seizures are not controlled
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Diagnosis of Epilepsy
History and the actual signs and symptoms Thorough physical examination and tests EEG and magnetic resonance imaging (MRI) Electrolyte imbalances

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Treatment
Control or eliminate cause Antiepileptic drugs and patient teaching Ketogenic diet Biofeedback Surgery

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Treatment of Status Epilepticus

Care is focused on supporting vital signs and preventing injury Intubation and respiratory support

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 Time the seizure began and the time it ended What the patient was doing just before the seizure (Was the patient picking at clothing?) Where in the body the seizure began, what parts of the body are involved Which way eyes are moving, whether they constrict or dilate, deviate to the right or the left, or roll upward
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Observations to Make During a Seizure

Observations to Make During a Seizure (cont .) Which side the head turns toward
Whether the patient cries out or screams as the seizure begins Whether there is evidence of repetitive movements: lip smacking, chewing, grimacing, tapping, or pill rolling

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Observations to Make During a Seizure (cont.) Whether movements are bilateral and
symmetrical Incontinence of urine or stool, vomiting, frothing at the mouth, or bleeding Whether the patient becomes apneic or cyanotic Changes in skin color or profuse perspiration
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Postictal Assessment
After a patent airway is ensured
Length of time before regaining awareness Presence of lethargy or confusion Presence of headache Presence of speech impairment Presence of muscle soreness Whether there was an aura before the seizure began Effects of the seizure on the patients vital signs
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Planning and Implementation

Expected outcomes are written for the individual patient and the type of seizure disorder, possible triggers, and manifestations Safety considerations Patient and family teaching

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Audience Response Question 1

Nursing care of a patient who had a recent seizure episode includes which nursing intervention(s)? (Select all that apply.) 1.Assess for injuries. 2.Check the glucose level. 3.Reassure and reorient patient. 4.Provide uninterrupted periods of sleep and rest. 5.Provide a 24-hour sitter.
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Transient Ischemic Attack

Brief interruption in blood flow Warnings of more serious neurologic event Symptoms generally last no more than an hour and completely resolve without residual deficits Thorough history

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 Blood tests, MRI, and EEG Angioplasty procedure with stent implantation or a carotid endarterectomy Diet, lifestyle modification, and medication to prevent platelet aggregation

Transient Ischemic Attack (cont.) Carotid duplex ultrasound

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Cerebrovascular Accident (Stroke, Brain Attack)

Etiology
Atherosclerosis
predispose to thrombus formation or plaque emboli

Risk factors-modifiable
Smoking, cocaine, ETOH >2 drinks/day, heart dz, DM, HTN, High cholesterol, sedentary, elevated RBC, TIAs, OCs, HRT,

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Cerebrovascular Accident (Stroke, Brain Attack)

Risk factors-non-modifiable
Age >65 Heredity Asymptomatic carotid bruit Prior CVA African American-60% Men-30%
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Cerebrovascular Accident (Stroke, Brain Attack)

Pathophysiology
Cerebral thrombosis-blood clot Embolus-traveling clot Intracerebral hemorrhage-ruptured blood vessels Pressure on a blood vessel-tumor

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 Caution people about the dangers of using cocaine or methamphetamine Both of these drugs can cause vasoconstriction and brain ischemia Cocaine may also cause hemorrhage Using these drugs causes a fivefold increase in the incidence of stroke The incidence of this type of stroke has greatly increased in young adults
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Dangers of Cocaine or Methamphetamine Use

Major Arteries Supplying Bloodessess s to the Brain

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Cerebral Aneurysm and Arteriovenous Malformation

Aneurysm
An abnormal ballooning of an artery wall

Arteriovenous malformation (AVM)

A congenital abnormality that is a tangled mass of malformed, thin-walled, dilated vessels that form an abnormal communication between the arterial and venous systems

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Dissected Circle of Willis Showing a Large Cerebral Aneurysm

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Warning Signs of Stroke

Teach people to seek immediate medical attention in an emergency department if any of the following warning signs of stroke appear
Sudden weakness, numbness, tingling, or loss of feeling in the face, arm, or leg Sudden trouble seeing in one or both eyes; double vision Sudden confusion, slurred speech, trouble talking, or difficulty understanding what others are saying
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Warning Signs of Stroke (cont.)

A sudden, severe headache for no known reason Sudden trouble walking, dizziness, or a feeling of spinning around Loss of balance or coordination Blackouts

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Warning Signs of Stroke (cont.)

Should any of the warning signs occur, ask the person to
Smile Shrug the shoulders Repeat a sentence or saying what you say first Tell you who and where he or she is

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Stroke Signs and Symptoms

Location of the clot or bleed Motor function deficits Language disorders Emotional responses Memory and judgment Spatial-perceptual deficits Bladder and bowel incontinence
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Stroke Diagnosis
MRI or cerebral angiogram EEG Brain scans Transcranial Doppler flow studies Carotid artery Doppler studies Testing for blood levels of glutamate Lumbar puncture
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Stroke Treatment
Maintain an open airway Fluids and antihypertensives Temperature control Alteplase or systemic tissue plasminogen activator and other medications Surgical procedures

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Each Area of the Brain Controls a Particular Activity

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Homonymous Hemianopsia

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Complications of Stroke
Extension of hemorrhage or rebleed Seizures Hydrocephalus

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Nursing Management of Stroke

Phase 1initial care Phase 2rehabilitation efforts Phase 3continuity of care

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Phase I
Assessment Nursing diagnosis Planning
Maintain an adequate airway Establish baseline data regarding vital signs, LOC, neuromuscular function, and neurologic status Preserve joint and muscle function Prevent complications that may interfere with rehabilitation
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Phase I (cont.)
Implementation
Amount of activity and cause of stroke Dysphagia and speech therapy

Evaluation

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Comparison of Deficits

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Phase II
Plans for rehabilitation should begin the moment the patient is admitted Various members of the health care team collaborate with the patient and family to help resolve both psychosocial and physical problems The stroke patient can be prone to rapid mood swings and spontaneous weeping
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Phase III
Discharge and referrals Visiting nurse Continued rehabilitation

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Brain Tumor-pp.539
Etiology Pathophysiology Signs and symptoms Diagnosis Treatment
Surgery Radiation therapy Chemotherapy
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Nursing Management of Brain Tumors

Routine neurologic assessments including activities of daily living Pain assessment and control

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Complications of Brain Tumors

Hydrocephalus Intercerebral hemorrhage

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Bacterial Meningitis-pp.541
Etiology and pathophysiology
Meningitis immunization

Signs and symptoms

Brudzinskis sign Kernigs sign

Diagnosis

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Bacterial Meningitis (cont.)

Treatment
Antibiotics Dexamethasone Anticonvulsive drugs Analgesics

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Viral Meningitis
Signs and symptoms Examination of the CSF Nursing management
Assessment Diagnosis Planning (expected outcomes) Implementation Evaluation
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Viral Meningitis (cont.)

Expected outcomes
Conserve the strength of the patient Prevent seizures Promote healing

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Encephalitis-pp.544
Etiology and pathophysiology
Protect against mosquitoes and ticks

Signs and symptoms Diagnosis Treatment Nursing management Complications

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Brain Disorders
Brain abscess Headaches Migraine headaches
Finding foods that trigger a migraine headache Complementary and alternative therapies

Cluster headaches Tension headaches

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Trigeminal Neuralgia (Tic Douloureux) Etiology

Pathophysiology Signs and symptoms Diagnosis Treatment Nursing management

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Bells Palsy
Etiology
Edema and ischemia of facial nerve Herpes simplex virus Stress Exposure to cold Pregnancy

Diagnosis Treatment
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