1|X ia mo n Common Neurologic Manifestation HEADACHE y a.k.a.

''cephalgia'' y one of the most common physical complaints PRIMARY HEADACHE y no organic cause Migraine y characterized by periodic and recurrent attacks of severe headaches y familial tendencies y abnormal metabolism of serotonin y triggered by menstrual cycle, bright lights, alcohol, food rich in tyramine, MSG, and milk products STAGES OF MIGRAINE y Prodrome o hours to days before attack o characterized by: o depression and food cravings o feeling cold o diarrhea or constipation y Aura Phase o last for less than an hour o characterized by visual disturbances and may be hemianopic o right time to take meds! y Headache phase o severe and incapacitating o often associated with photophobia, nausea and vomiting o ranging from 4-72 hours o subdural hematoma dead. o No to work y Recovery Phase o pain gradually subsides o sleeps for extended periods o exhaustion and mood changes are common OTHER TYPES OF HEADACHE 1. Cluster headaches y unilateral and come in clusters of one to eight daily y localized to the eye and orbit and radiating to facial and temporal regions y accompanied by watering of the eye and nasal congestion y attack last for 30-90 minutes. 2. Cranial Arteritis y headache in older people 50 year old and above y a.k.a 'temporal headache' y a.ka. 'giant cell headache' Xiamon| 1

2|X ia mo n y manifestations: fatigue, malaise, weight loss (chronic) , and fever y almost the same as thrombophlebitis 3. Tension Headache y Characterized by a steady, constant feeling of pressure y A weight on top of my head.

SECONDARY HEADACHE y Associated with organic cause o Brain tumors o Aneurysms (problem on Blood vessel, hindi kaya ang pressure) o Subarachnoid hemorrhage and brain injury o Stroke and severe hypertension (Malignant Hypertension- severe hypertension + nose bleed) o Meningitis Nursing Interventions y Prophylactic medications may be used for recurrent migraines (beta blockers, serotonin antagonist) y Migraines and cluster headaches require abortive (triptans) medications. y Provide comfort measure o Quiet, dark room (away from nurses station) o Massage(promote circulation) o Local heat for tension (Dilate BV=increased circulation) y Identify triggers and develop preventive strategies and lifestyle changes y Provide medication instruction and treatment regimen y Implement stress reduction techniques y Implement non pharmacologic therapies (DBE, moist pack, massage) y Encourage healthy lifestyle and health promotion activities.

Increased Intracranial Therapy 1. Monro-Kellie hypothesis: y Brain tissue (1400 g), blood (75 mL), and CSF (75 mL) y Shifting or displacing CSF to attain normal pressure (compensatory mechanism of brain) y Occurs due to alterations in: i. Intracranial pressure ii. Posture iii. Systemic oxygenation iv. CO2 levels y Increased CO2= Increased BV dm= Increased blood flow= Increased ICP v. Blood pressure y Increased ICP decreases cerebral perfusion, causes ischemia, cell death, and edema.. death 2. Autoregulation- refers to the brain s ability tp change the diameter of blood vessels to maintain cerebral blood flow ( Increased ICP is tantamount to Cardiomyopathy= Decreased C.O and Decreased C. Perfusion= M.I. = Death) Xiamon| 2

3|X ia mo n Complications: i. Herniation is the shifting of the brain tissue ii. Cerebral Edema- abnormal accumulation of fluid in the brain tissue iii. Diabetes Insipidus- Decreased secretion of ADH (Polyuria e.g beer=ihi. Altered ADH) iv. SIADH- increases the secretion of ADH (Fluid retention-oliguria) EARLY MANIFESTATIONS y Changes in LOC y Any changes in condition: o Restlessness, confusion o Increased drowsiness o Increased respiratory effort (increased RR. Use of accessory muscle. Suprasternal retraction. Intercostals retraction. Substernal retraction.) y Pupillary changes and impaired ocular movements y Weakness in one extremity or one side. y Headache: constant, increase in intensity by movement or straining. y Late Manifestation y Respiratory and Vasomotor Changes y Changes in Vital signs o Increase in systolic BP (pulse pressure-gap. Normal Pulse pressure is 20-40 mmHg) o Widening of Pulse Pressure o Slowing of the heart rate o Fluctuations of pulse rate o Temperature increase o CUSHING s TRIAD- bradycardia, hypertension, and bradypnea y Stupor y Coma y Death Management y Monitoring ICP (normal ICP 7-15 mmHg; higher than 24 mmHg= increased ICP mannitol. o Purpose  Quantify degrees of elevation  Initiate appropriate treatment  Provides access for CSF sampling and drainage  0 line=ear level aligned  Types:  subdura  VENTRICULAR-accurate  Subarachnoid  Intraparenchymal  Epidural  Intraventricular y Decreasing cerebral edema o Osmotic Diuretis-nephrones.  Loop-ascending loop of Henle Xiamon| 3

4|X ia mo n IFC for Fluid monitoring  IV meds should act 3-5 min  oral- 30 min - 1 hour o Corticosteroid (dexamethasone)-edema o Fluid restriction Maintaining cerebral perfusion pressure (CPP 7O-90) o Dobutamine HCl (+) inotropic - Increased contraction= increased C.O  (-) chromotropic - Heart rate/beats/minute o Maintaining CPP At 70 mmHG or higher  Cerebral Perfusion Pressure(70-90 mmHg) If lowered= DOBUTAMINE agad. Reducing CSF and intracranial blood flow o CSF drainage o hypervenilation Controlling fever o decrease edema o antipyretics o cooling blankets o prevent shivering Maintaining Oxygenation o 02 supplemental 21% ang oxygen sa air.  Less than 21% ang sa Baguio.. mga 16% lang..so ditto nagtrain ang Azkals para maincrease ang RBC. And RBC is the carrier of oxygen  nasal cannula- 22-24 % o Hemoglobin saturation Reducing metabolic demands o Administering high doses of Barbiturate  Propofol and Pentobarbital are EGG based. So sa may allergy dapat hindi ito ibigay Nx considerations o Monitor VS frequently o Prepare endotracheal intubation o Mechanical ventilator Nursing Interventions o Maintaining airway patency o Suctioning with care o Hyperoxygenation and before and after suctioning o Auscultation of lung fields every 8 hours  Crackles, or wheezing etc o Elevation of head of board (high back rest) o Preventing infection  Maintain aseptic technique  Monitor signs and symptoms of meningitis y Stretch meninges- nape pain- Bruzinky signs. Ternicke Optimizing Cerebral Tissue Perfusion o Keep head in neutral position o Xiamon| 4

5|X ia mo n  Straight position Avoid extreme rotation of head and flexion of neck Avoid use of valsalva maneuver Increase fiber in diet  Green leafy vegetables o Avoid enemas  Stimulate CN X o Exhale when moving o Avoid emotional stress o Minimize environmental stimuli. Maintaining fluid balance o assess skin turgor, mucous membrane and UO o slow IV fluids o Monitor onset of diabetes insipidus  Polyuria o NX CONSIDERATIONS  frequent oral care  lubricate lips o SIADH  nx considerations y restrict fluid intake y administer diuretics y check mental status o o o INTRACRANIAL SURGERY y Craniotomy-opening of the skull o techniques  supratentorial approach y frontal lobe to temporal  infratentorial approach y occipital  Transshenoid approach y -nose- for pituitary tumors o Purposes:  Remove tumor  Relieve elevated ICP  Evaluate a blood clot  Control hemorrhage CRANIECTOMY o -excision of a portion of the skull Cranioplasty o repair of a cranial defect using a plastic of metal plate. Burr Holes o circular opening for exploration or diagnosis o to provid access to ventricles o for shunting procedures Xiamon| 5

y y y

6|X ia mo n  VP shunting to aspirate a hemetoma or abscess to make a bone flap

o o

Preoperative Care y Preoperative Dx procedure o assess Dx and family understanding and preparation o Obtain baseline neurologic assessment Preoperative Meds o antiseizure o corticosteroids o hyperosmotic agents (Mannitol) o antibiotics

Post Op CAre y y care for ET TUBE reducing cerebral edema o osmotic diuretic (Mannitol) o dexamethasone (Decadron) IV q 6 hours -relieving pain and seizures o acetaminophen o codeine o morphine o antiseizure meds Manage sensory deprivation o inform family and periorbital edema post op o report increasing periorbital edema Maintaining cerebral tissue perfusion o maintenance of ET till full awake and spontaneous respiration o watch out for decrease in LOC on the second day o vital signs and neuroassessment every 15min- 1 hr o Lying on unaffected sid post operatively keeping neck in neutral position Regulate Temperature o Cover patient appropriately o Apply ice bags o Use hypothermia blanket o Administer prescribed acetaminophen -Enhance self image o social interaction and social support o pay attention to grooming o cover head with turban and wig

ALTERATIONS IN MUSCLE TONE and MUSCLE FUNCTIONS Xiamon| 6

7|X ia mo n Muscle Weakness o --'lack of strength' o --inability to exert force with one's to the degree that would be expected given the individual's general physical fitness. o --common manifestation of neurologic disease o --can be sudden and permanent or progressive o True weakness  --'objective weakness'  --describes a condition where the instantaneous force exerted by the muscle is less than would be expected o Perceived weakness  --'subjective weaknes  --a condition where it seemed to the px Dx that more effort than normal is required to exert a given amount of force

PARESIS o -a condition typtfied by partial force of movements or impaired movement o --Monoparesis-one leg or one arm o --Paraparesis-both legs or both arm o --Hemiparesis-one arm or one leg on either side of the body o --Quadraparesis- all four limbs o --Gastroparesis-impaired stomach emptying (dyspepsia) o Opthalmoparesis (problem on eye opening) PARALYSIS o -complete loss of muscle function for one or more muscle groups o -can cause loss of feeling or loss of mobility in the affected area  Hemiplegia-one sided paralysis  Paraplegia-paralyris of the tone, extremity  Quadriplegia-all four limbs (walang paralysis sa upper extremities) ATROPHY o -partial or complete wasting away of a part of the body o -cause include  poor nourishment KWASHIORKOR  poor circulation  loss of nerve supply to target atrophy  -disuse or lack of exercise o CACHEXIA  -a general weight loss and wasting occuring in the course of a chronic disease or emotional disturbance o SARCOPENIA  -progressive reduction in muscle gross section and mass with aging

Altered LOC Xiamon| 7

8|X ia mo n is not a d/o itself, it is a function and symptom of multiple pathophysiologic phenomena Criteria: o Does not follow simple commands o Needs persistent stimuli to achieve a state of alertness. Disoriented Akinetic Mutism o unresponsive to the environment in which the patient makes no movement or sound but sometimes opens the eye. Persistent vegetative state o wakeful but devoid of conscious content, without cognitive, affective mental function o 0-4 mins-no brenda o 4-6 mins- not likely o 6-10 mins- likely o More than 10 mins- brenda probably certain. Locked-in Syndrome o Unable to move or respond except for eye movement

y y

y y

7 coma 7-8 ET intubation 3 deep coma - abnormal papillary and motor response- neurologic disease - comatose and papillary reflex are preserved- metabolic/toxic disorders -anisocoria- eyes CNS

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9|X ia mo n Long term altered LOC complication o Resp failure o Pneumonia o Pressure ulcers  subQ  muscle  bones o aspiration o deep vein thrombosis  virchow s triad y venous stasis y hypercoagulation y endothelial injury

Nursing Intervention y Maintain patent airway o adequate airway and ensure ventilation o aspiration precaution (high fowlers) o suction secretions (10-15 secs) y suction secretions o position to lateral or semi prone position (recovery position) o provide oral hygiene o chest physiotherapy o the most important assessment before physiotherapy  check gag reflex. Then auscultate breath sounds  (+) crackles o Sometimes with nebulization o Best time: early morning o Auscultate chest every 8 hours o Protecting the client o Raise padded side rails o Avoid restrains if possible  Shoulder  Hips  Knees o Providing privacy and speaking to the client when rendering care o Maintaining fluid balance and manage nutrition meds o Assess hydration status o Regulate IVF (TPN- total parenteral nutrition) o NGT o Providing mouth care o Inspect for dryness, inflammation o Frequent oral care o Petrolatum on the lips o Move endotracheal tube daily o Maintaining skin and joint integrity

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10 | X i a m o n Log rolling schedule to provide kinesthetic, proprioceptive and vestibular stimulation o Avoid dragging o Maintaining proper body alignment o Passive ROM exercises o Prevent footdrop o Trochanter rolls Preserve corneal integrity o Cleanse with cotton balls moistened with sterile NSS o Artificial tears every 2 hours (15 mis allowance pag madami) o Ice pack for periocular edema o Eye patch with caution Achieving thermoregulation o High fever caused by infection o Slight fever caused by dehydration o TSB and decreasing linens o Administer antipyretics Preventing urinary retention o Palpate bladder for any signs of retention  Max bladder capacity 1k 1.5k  Urogenic bladder- distended  Suprapubic tap o Insert IFC o Observe fever and cloudy urine o Intermittent catheterization o Condom catheter  Urinary incontinence o Bladder training Promoting bowel function o Assess abdominal sound o Assess abdominal girth o Rectal exam for fecal impaction o Stool softeners o Glycerine suppository o Enema Providing sensory stimulation o Maintain the sense of daily rhythm o Touch and talk is encouraged o Avoid negative comments o Orient to time and place o Sound of the client s workplace may be introduced o Fav book, tv, radio enjoyed o Watch out for aroused from coma o Videotape of family and social events o

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