NCLEX-RN: Medical–Surgical Nursing

Medical–Surgical Nursing: Seizure Disorders

Focus topic: Medical–Surgical Nursing

Medical–Surgical Nursing: Convulsions/Seizures

Focus topic: Medical–Surgical Nursing

Definition: Temporary alterations in brain function resulting in sudden episodes of altered consciousness or involuntary movement expressing themselves as a changed mental state, tonic or clonic movements, and various other symptoms. Seizures may occur as isolated events, possibly after head trauma, and do not persist once the underlying cause is eliminated.

Characteristics
A. Causes: cerebral trauma, congenital defects, epilepsy, infection, tumor, circulatory defect, anoxia, metabolic abnormalities, excessive hydration, idiopathic, acute alcohol withdrawal.
B. Classification.

  • Tonic convulsion: sustained contraction of muscles.
  • Clonic convulsion: alternating contraction– relaxation of opposing muscle group.
  • Epileptiform: any convulsion with loss of consciousness.

Assessment
A. Identify if aura present.
B. Observe type of motor activity.
C. Observe pattern of seizure activity.
D. Identify length of seizure activity.
E. Evaluate loss of bowel or bladder control.
F. Evaluate loss of consciousness.
G. Observe for signs of respiratory distress.
H. Identify characteristics during the postictal state.

Implementation
A. Observe and record characteristics of seizure activity.

  • Level of consciousness.
  • Description of any aura.
  • Description of body position and initial activity.
  • Motor activity: initial body part involved, character of movements (tonic/clonic), progression of movement, duration, biting of the tongue.
  • Respiration, color.
  • Pupillary changes, eye movements.
  • Incontinence, vomiting.
  • Total duration, frequency, number of seizures, injuries.
  • Postictal state.
    a. Loss of consciousness.
    b. Sleepiness.
    c. Impaired speech, motor or thinking.

B. Protect client from trauma.

  • Ensure patent airway; may need to use a nasal airway.
  • Do not force any object between teeth if they are already clenched.
  • Avoid use of any restraints; loosen restrictive clothing.
  • Remove any objects from environment that may cause injury.
  • Stay with client.
  • If the client is standing, place him/her on the floor; protect head and body from hard surfaces.
  • Be prepared to suction.
  • Keep side rails up; pad side rails.

C. Provide nursing care after seizure.

  • Keep turned to side to prevent aspiration.
  • Reorient to environment when awakened.

Medical–Surgical Nursing: Epilepsy

Focus topic: Medical–Surgical Nursing

Definition: A combination of several disorders characterized by chronic, recurrent seizure activity; a symptom of brain or CNS irritation. A seizure is an abnormal, sudden, excessive discharge of electrical activity within the brain.

Characteristics
A. Incidence in United States may be as low as 1 million or as high as 2.5 million—many clients hide their seizure disorder.
B. Major problems may be an electrical disturbance (dysrhythmia) in nerve cells in one section of the brain.
C. Seizures are associated with changes in behavior, mentation and motor or sensory activity.
D. Causes may be related to several factors.

  • Genetic factors, trauma, brain tumor, circulatory or metabolic disorders, toxicity, or infection.
  • May be symptoms of underlying brain pathology such as scar tissue, vascular disease, meningitis, or secondary to a birth injury.
  • Heredity may play a part in absence, akinetic, or myoclonic seizures.

E. Diagnostic tests include CT to determine underlying CNS changes, EEG for a distinctive pattern, MRI, blood studies, lumbar puncture, etc.

Assessment
A. Observe specific phases of seizure activity.

  • Occurs without warning or following an aura (peculiar sensation that warns of an impending seizure—dizziness, visual or auditory sensation).
  • Behavior at onset of seizure.
    a. Change in facial expression—fixation of gaze, flickering eyelids, etc.
    b. Sound or cry at time of seizure.

B. Observe movements of body.

  • Tonic phase—parts of body involved, length of time (usually 10–20 seconds).
  • Clonic phase—parts of body that jerk, sequence of jerking movements, how long activity lasts (usually 30–40 seconds).

C. Observe behavior following seizure.

  • State of consciousness, orientation.
  • Motor ability, speech ability, activity.

D. Seizure history through client report or observation.

  • Seizure onset, pattern or sequence of progression, precipitating events, frequency, description.
  • Whether seizure is a simple staring spell or prolonged convulsive movements.
  • Excess or loss of muscle tone or movement.
  • Disturbance of behavior, mood, sensation, and/ or perception.
  • Prodromal signs or symptoms: mood changes, irritability, insomnia, etc.
  • Effect of epilepsy on life and lifestyle (work limitations, social interaction, psychological adjustment).

Generalized Seizures: Four Types
A. Tonic–clonic seizures, traditionally known as “grand mal.”

  • May begin with an aura, then a tonic phase—symmetrical stiffening or rigidity of muscles, particularly arms and legs, followed by loss of consciousness.
  • Clonic phase follows—hyperventilation with rhythmic jerking of all extremities.
  • May be incontinent of urine and feces.
  • May bite tongue.
  • May last 2–5 minutes.
  • Full recovery may take several hours.

B. Absence seizures, formerly “petit mal.”

  • Brief, often just seconds, loss of consciousness; almost no loss or change in muscle tone.
  • May occur 100 times/day. More common in children; may appear to be “daydreaming.”

C. Myoclonic seizures.

  • Characterized by a brief, generalized jerking or stiffening of the extremities; jerks may be single or multiple.
  • May occur as single movement or in groups; seizure may throw person to the floor.

D. Atonic or akinetic seizures, also called “drop attacks.”

  • Characterized by sudden, momentary loss of muscle tone.
  • Usually causes person to fall to the ground (injuries from falling are common).

Partial Seizures (Focal Seizures)
A. Simple partial seizure.

  • Localized (confined to a specific area).
    a. Motor symptoms: abnormal unilateral movement of leg or arm.
    b. Sensory symptoms: abnormal smell or sensation.
    c. Autonomic symptoms: Include tachycardia, bradycardia, increased respirations, skin flushing, epigastric distress.
    d. Psychic symptoms: May report déjà vu or fearful feelings.
  • Client remains conscious throughout episode and may report an aura before seizure takes place.

B. Complex partial (psychomotor) seizure; may progress to generalized tonic–clonic.

  • Area of brain most involved is temporal lobe (thus this type of seizure is called psychomotor).
  • Characterized by a period of altered behavior and automatism (client is not aware of behavior); evidenced by such mannerisms as lip smacking, chewing, picking at clothes, focal motor activity, such as posturing or jerking movements.
  • Client loses consciousness for a few seconds.

C. Idiopathic or unclassified seizures.

  • This type of seizure accounts for half of all seizure activity.
  • Occurs for no known reason and fits into no generalized or partial classification.

Implementation
A. Prevent injury during seizure.

  • Remove objects that may cause harm.
  • Remain with client during seizure.
  • Do not force jaws open during seizure.
  • Do not restrict limbs or restrain.
  • Loosen restrictive clothing.
  • Turn head to side, if possible, to prevent aspiration and allow secretions to drain.
  • Check that airway is open. Do not initiate artificial ventilation during a tonic–clonic seizure.

B. Observe and document seizure pattern.

  • Note time, level of consciousness, and presence of aura before seizure.
  • Record type, character, progression of movements.
  • Note duration of seizure and client’s condition throughout.
  • Observe and record postictal state.

C. Administer and monitor medications.

  • Seizure control may be achieved with one or a combination of drugs.
  • Dosage is adjusted to achieve seizure control with few side effects.
  • Medications must be given continuously and on time throughout life of client to maintain therapeutic blood levels.
  • Dilantin (phenytoin).
    a. Prevents seizures through depression of motor areas of the brain.
    b. Side effects: gastrointestinal (GI) disturbance, visual changes, rash, anemia, gingival hyperplasia.
    c. Check complete blood counts (CBC) and calcium levels.
    d. Give PO drug with milk or meals; supplemental vitamin D and folic acid.
  • Valium (diazepam).
    a. Give to stop motor activity associated with status epilepticus; for restlessness.
    b. Side effects: If given IV, monitor for respiratory distress.
  • Luminal (phenobarbital).
    a. Reduces responsiveness of normal neurons to impulses arising in focal site.
    b. Side effects: drowsiness, ataxia, nystagmus, respiratory depression.
  • Tegretol (carbamazepine).
    a. Inhibits nerve impulses by limiting influx of sodium ions across cell membranes.
    b. Give with meals; monitor for side effects—diplopia, blurred vision, ataxia, vomiting,leukopenia.
  • Klonopin (clonazepam).
    a. Decreases frequency, duration, and spread of discharge in minor motor seizures (absence, akinetic, myoclonic seizures).
    b. Side effects: lethargy, ataxia, vertigo, thrombocytopenia— monitor CBC.
  • Neurontin (gabapentin).
    a. Do not take 1 hour before or less than 2 hours after antacids.
    b. Monitor liver function studies regularly (as ordered) to detect early signs of hepatitis or liver problems.
  • Cerebyx (fosphenytoin).
    a. Thought to modulate sodium channels of neurons, modulate calcium flux across neuronal membranes, enhance sodium–potassium ATPase activity of neurons and glial cells.
    b. Must be prescribed in PE units.
    c. Side effects: nystagmus, dizziness, somnolence, drowsiness.

D. Promote physical and emotional health.

  • Establish regular routines for eating, sleeping, and physical activity.
  • Avoid alcohol, stress, and excessive fatigue.
  • Foster self-esteem and promote self-confidence.
  • Contact Epilepsy Foundation of America.
    a. Recent studies suggest specially trained dogs can tell when a seizure is about to happen.
    b. For clients with poorly controlled seizures, suggest referral to special programs.

E. Surgical treatment.

  • When attempts to control seizure fail, excision of tissue involved in the seizure activity may be
    a safe and effective treatment.
  • Goal: control—reduce client’s uncontrolled seizures.
  • Postop care—general postop care for a client having intracranial surgery.

Medical–Surgical Nursing

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Medical–Surgical Nursing: Trauma

Focus topic: Medical–Surgical Nursing

Medical–Surgical Nursing: Head Injury

Focus topic: Medical–Surgical Nursing

Definition: A trauma to the skull resulting in varying degrees of injury to the brain by compression, tension, and/or shearing force. A traumatic brain injury (TBI) is a serious form of injury.

Types of Injury
A. Concussion—violent jarring of brain within skull; temporary loss of consciousness.

  • Symptoms are worse at point of impact.
    a. Immediate loss of consciousness (usually no longer than 5 minutes).
    b. Amnesia for events surrounding injury.
    c. Headache.
    d. Drowsiness, confusion, dizziness.
    e. Visual disturbances.
    f. Possible brief seizure activity, with transient apnea, bradycardia, pallor, hypotension.
  • Postconcussion syndrome.
    a. Persistent headache.
    b. Dizziness.
    c. Irritability, insomnia, tiredness.
    d. Impaired memory and concentration, learning problems.
    e. May last a few days to several months.

B. Contusion—bruising, injury of brain.

  • Acceleration—slower-moving contents of cranium strike bony prominences or dura (coup).
  • Deceleration—moving head strikes fixed object and brain rebounds, striking opposite side of cranium (countercoup).

C. Fracture—linear, depressed, compound, comminuted, closed or open. Location alters the presentation of symptoms.

  • Battle’s sign (postauricular ecchymosis) and raccoon eyes (periorbital ecchymosis usually associated with tear in dura and subsequent leakage of CSF.
  • Rhinorrhea (CSF leakage from the nose) or otorrhea (CSF leakage from the ears) generally confirms the fracture has traversed the dura. The risk of infection is increased with CSF leak. Antibiotics may be given to prevent meningitis.

D. Hematoma.

  • Epidural—most serious; hematoma between dura and skull from tear in meningeal artery; forms rapidly.
  • Subdural—under dura; due to tears in veins crossing subdural space; forms slowly.
  • Intracerebral—usually in frontal and temporal lobes; usually caused by gunshot wounds, stabbing, depressed skull fractures, long history of systemic hypertension, contusion.

E. Subarachnoid hemorrhage—bleeding directly into brain, ventricles, or subarachnoid space.

  • Monitor symptoms suggestive of complications.
    a. Keep BP within normal limits—administer drugs as ordered.
    b. Administer phenobarbital to control seizures; codeine for pain; corticosteroids for edema; fibrinolytic inhibitor (Amicar [aminocaproic acid]) to minimize risk of rebleed.
  • Maintain bed rest, prevent exertion, keep room
    quiet and dark.
  • Prevent straining, administer laxatives and stool softeners.
  • Avoid stimulants like caffeine (e.g., coffee).

F. Intracerebral hemorrhage—usually multiple hemorrhages around contused area.

Assessment
A. Level of consciousness, unconsciousness, or confusion.
B. Patent airway and breathing pattern.
C. Headache, nausea, vomiting.
D. Pupillary changes—ipsilateral dilated pupil.
E. Changes in vital signs, reflecting increased intracranial pressure or shock.
F. Vasomotor or sensory losses.
G. Rhinorrhea, otorrhea, nuchal rigidity.
H. Overt scalp or skull trauma.
I. Positive Babinski sign (dorsiflexion of toes when bottom of foot is stroked).

Implementation
A. Primary nursing objective is to recognize, prevent, and treat complications; observe for signs of increased intracranial pressure.
B. Maintain adequate respiratory exchange—increased CO2 levels increase cerebral edema.

  • Maintain patent airway.
  • Encourage to avoid coughing (increases ICP); may require frequent suctioning.

C. Complete neurological assessment, including Glasgow Coma Scale, every 15 minutes initially, then every hour until stable, then every 4 hours.

  • Awaken client as completely as possible for assessment.
  • Maintain slight head elevation to reduce venous pressure.

D. Monitor temperature—utilize hypothermia as ordered to reduce fever.
E. Control pain and restlessness.

  • Avoid morphine, a respiratory depressant that might increase ICP.
  • Use codeine or other mild, safe analgesic.

F. Monitor and treat seizure activity—administer anticonvulsants as ordered.

G. Observe for complications.

  • Shock—significant cause of death.
  • Cranial nerve paralysis.
  • Rhinorrhea (fracture ethmoid bone) and otorrhea (temporal).
    a. Check discharge—bloody spot surrounded by pale ring called halo or ring sign.
    b. Do not attempt to clean nose or ears.
    (1) Do not suction nose.
    (2) Instruct client not to blow nose.
  • Ear—drainage of CSF from the ear indicates damage to the base of the brain and a danger of meningitis.
    a. Inspect ear for drainage of CSF.
    b. Loosely cover ear with sterile, dry dressing.
  • Eye—loss of corneal reflex may contribute to corneal irritation, keratitis, blindness.
    a. Assess corneal reflex and signs of irritation.
    b. Instill artificial tears or close eyelids and cover with moistened pads to protect cornea.
  • Fluid and electrolyte imbalance—diabetes insipidus.

H. Prevent infection.

  • High risk of meningitis, abscess, osteomyelitis, particularly in presence of rhinorrhea, otorrhea.
  • Maintain strict asepsis.

I. Prevent complications of immobility.

  • Continue range-of-motion activities.
  • Prevent contractures.

J. Establish individualized rehabilitation program.

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