[2.2] NEURO Part II (Seizure Disorders and Cerebrovascular Disorders)

From Ms. Lorelie Pomentil's lecture last July 17, 2025

Seizure Disorders

Sudden excessive electrical discharges in the brain

1. Partial

2. Generalized

What are the two main types of seizure disorders?

Partial

Seizure Disorders: Begin in one part of the brain

Generalized

Seizure Disorders: Electrical discharges in the whole brain

Jacksonian Seizure

What is/are the type/ of seizure/s under partial?

• It starts from the distal area (fingers/hands)

• It progresses to the adjacent area

Describe how Jacksonian seizure starts and progresses

1. Grand mal / Tonic clonic Seizure

2. Petit mal / Absence Seizure

What is/are the type/ of seizure/s under generalized?

1. Tonic

2. Clonic

Generalized seizure (Grand mal): Identify what is being described

1. Rigidity

2. Jerky

Petit mal / Absence

Generalized seizure: Blank stare

1. Safe

2. Non-stimulating

What are the two main concepts of seizure precaution under environment?

1. Bed = Lowest

2. Side Rails = Padded and raised

3. Clothing = Loose

4. Bed side = O2 and Suction

Seizure precaution: Identify how the following should be set under the concept of a safe environment

1. Bed

2. Side Rails

3. Clothing

4. Bed side

1. Admit = Private room

2. Light = Dim

3. Visitors = Light

4. Avoid = Noise and Stress

Seizure precaution: Identify how the following should be set under the concept or a non-stimulating environment

1. Admit

2. Light

3. Visitors

4. Avoid

Airway and Safety

Nursing Management: During a seizure, what is/are the priority? If there is no context in the question, which should you prioritize more?

1, 2, 3, 4, 5, 7, 11

1. To prognosticate

2. Dignity

3. Done when the patient is sitting or standing; Safety

4. Ideal if possible; Prevents airway obstruction and aspiration

5. If side lying is not possible

6. Remove

7. Safety

8. Temporomandibular Joint (TMJ) Damage

9. Aspiration; DO NOT INSERT ANYTHING

10. Skeletal Injury

11. FOB; If patient is on the floor, protect the head

Nursing Management of Seizure Disorders: Pick what should you do among the following and give the rationale behind each:

1. Time the seizure

2. Provide the privacy

3. Ease patient to the floor

4. Side lying position

5. Supine

6. Leave furniture around patient

7. Protect the head

8. Forced mouth opening

9. Insert oropharyngeal airway

10. Restraint

11. If in bed, remove pillow, and raise side rails

Airway

Nursing Management: After seizure, what is/are the priority?

1. Side-lying position

2. Re-orient patient upon awakening

3. Continue monitoring the patient until fully conscious

Nursing Management: After a seizure, identify what you should do.

1. Benzodiazepines

2. Anticonvulsants

Medical Management (Seizure Disorders): What are the types of drugs prescribed to patients with seizure/seizure disorders

Benzodiazepines

Medical Management (Seizure Disorders): These are anxiolytics, CNS depressants, and/or “Downers”

Benzodiazepines

Medical Management (Seizure Disorders): Rescue drugs during active seizures

Diazepam

Medical Management (Seizure Disorders): Most common benzodiazepine

a. Benzodiazepines

Midazolam, Lorazepam, Diazepam

a. Benzodiazepines
b. Anticonvulsants

b. Anticonvulsants

Phenytoin

a. Benzodiazepines
b. Anticonvulsants

Anticonvulsants

Medical Management (Seizure Disorders): Maintenance medication

Phenytoin (Dilantin)

Medical Management (Seizure Disorders): Most common anticonvulsant

b. Anticonvulsants

Seizure prevention

a. Benzodiazepines
b. Anticonvulsants

b. Anticonvulsants

Taken daily to prevent seizures

a. Benzodiazepines
b. Anticonvulsants

10 - 20 mcg/mL

What is the therapeutic range of anticonvulsants?

Gingival hyperplasia

• Soft brittle toothbrush

• Regular dental checkup

Medical Management (Seizure Disorders): What is the side effect of phenytoin? How do you manage it?

The gums are tender and inflammed

Medical Management (Seizure Disorders): What happens to the gums when one has gingival hyperplasia?

Antacids

• They reduce the effects of phenytoin

Medical Management (Seizure Disorders): What is contraindicated for patients taking anticonvulsants or phenytoin? Why?

FALSE

• Stroke is never an accident

TRUE or FALSE: Stroke is an accident

Cerebrovascular Disorders

Functional abnormality of the CNS from disruption of blood supply to a part of the brain

1. Ischemic

2. Hemorrhagic

What are the two major categories of Cerebrovascular Disorders?

Ischemic Stroke

Cerebrovascular Disorders: Also known as “Brain Attack”

Ischemic Stroke

Cerebrovascular Disorders: Decreased perfusion to the brain tissue

ATE-DHA

1. Atherosclerosis (fats)

2. Thrombus (clots)

3. Embolism (dislodged/foreign)

4. Diabetes Mellitus (viscous blood)

5. Hypertension

6. Atrial Fibrillation (complication is the problem)

Cerebrovascular Disorders: What are the causes of Ischemic Stroke?

Disruption of blood flow → Ischemia (Prolonged lack of O2) → Tissue Necrosis (Tissue Death) → Infarction (Necrotic tissue from ischemia)

• The same pathophys as MI (MI = Heart Attack; IS = Brain Attack)

Cerebrovascular Disorders: Explain the pathophysiology of Ischemic Stroke briefly.

Hemorrhagic Stroke

Cerebrovascular Disorders: Bleeding into the brain tissue, ventricles, and subarachnoid space

TRUE

• Nasa blood vessels dapat ang blood

TRUE or FALSE: The direct there should be no direct contact between the blood and brain

1. Primary intracerebral hemorrhage

2. Secondary intracerebral hemorrhage

Cerebrovascular Disorders: What are the two types of hemorrhagic stroke

Primary intracerebral hemorrhage

Cerebrovascular Disorders (Hemorrhagic Stroke): From spontaneous rupture of small vessels caused by uncontrolled hypertension

Secondary intracerebral hemorrhage

Cerebrovascular Disorders (Hemorrhagic Stroke): Associated with AVMs, cerebral aneurysm, neoplasm, or certain medications (anticoagulants)

Arteriovenous Malformation (AVM)

Tangled arteries and veins in the brain (present at birth) that lacks a capillary bed that leads to dilation of the arteries and veins that may eventually rupture

a. Arteriovenous malformation

'“Walking time bomb”

a. Arteriovenous malformation
b. Cerebral aneurysm

Cerebral Aneurysm

Dilation of weakened arterial wall at the brain

Thoracic Aortic Aneurysm

Abdominal Aortic Aneurysm

Give other types of aneurysm other than Cerebral Aneurysm

BE FAST

What is the assessment tool for stroke?

1. Balance

2. Eyes

3. Face

4. Arms

5. Speech

6. Time

What are the components of “BE FAST”?

Diplopia or unable to see out of one eye

BE FAST: Describe what should be seen under Eyes

Drooping one side when smiling

BE FAST: Describe what should be seen under Face

One arm drift downward

BE FAST: Describe what should be seen under Arms

Slurring or difficulty getting the words out right

BE FAST: Describe what should be seen under Speech

1. CT Scan

2. MRI

3. 12-Lead ECG

Cerebrovascular Disorders: What are the diagnostic tests for CVDs?

1. MRI

2. CT Scan

3. 12-Lead ECG

Cerebrovascular Disorders: Identify the diagnostics being described in the following statements

1. For continuous monitoring

2. Initial diagnostic test for stroke

3. For checking the presence of atrial fibrillation as a cause

1. Hemorrhagic (Bright = Blood)

2. Ischemic (Itim = Ischemic) [Penumbra Region]

Cerebrovascular Disorders: Identify what type of stroke is being described by the following CT Scan results:

1. Presence of bright white areas on the affected side

2. Presence of dark areas on the affected side

1. Thrombolytic Therapy

2. Anticoagulant Therapy

Cerebrovascular Disorders: What are the drugs prescribed for ischemic stroke?

1. Antihypertensives

2. Fresh frozen plasma and Vitamin K

3. Anticonvulsant: Phenytoin (Dilantin)

Cerebrovascular Disorders: What are the drugs prescribed for hemorrhagic stroke?

t-PA (Tissue Plasminogen Activator)

Cerebrovascular Disorders (Medical Management): What is the main treatment for Ischemic Stroke

Alteplase

Cerebrovascular Disorders (Medical Management): What is other term used to refer t-PA

1. Stroke must be ischemic

2. Age is 18 y.o. or older

3. Onset of 3 hours or less (4.5 hrs)

Cerebrovascular Disorders (Medical Management): What are the considerations for Thrombolytic therapy, specifically t-PA?

FALSE: More than 3 hours, the drug is no longer effective

TRUE or FALSE: t-PA should be administered for more than 3 hours but less than 5 hours

Warfarin (Coumadin)

Cerebrovascular Disorders (Medical Management): What is the drug of choice for anticoagulant therapy of Ischemic Stroke?

Aspirin

• Antiplatelet

• It can be given together with clopidogrel

Cerebrovascular Disorders (Medical Management): If warfarin is contraindicated for anticoagulant therapy in ischemic stroke, what could be an alternative?

a. Fresh Frozen Plasma

Cerebrovascular Disorders (Medical Management for Hemorrhagic Stroke):

Passive

a. Fresh Frozen Plasma
b. Vitamin K

b. Vitamin K

Cerebrovascular Disorders (Medical Management for Hemorrhagic Stroke):

Active

a. Fresh Frozen Plasma
b. Vitamin K

b. Vitamin K

Cerebrovascular Disorders (Medical Management for Hemorrhagic Stroke):

Increases the production of clotting factors in the liver

a. Fresh Frozen Plasma
b. Vitamin K

Phenytoin (Dilantin)

Cerebrovascular Disorders (Medical Management for Hemorrhagic Stroke): What is the drug of choice for increased risk for seizures?

1. Motor loss

2. Verbal deficits

3. Visual field deficits

4. Sensory loss

5. Joint deformities / Contractures

Cerebrovascular Disorders: What are the main classifications of clinical manifestations?

1. Hemiplegia

   1. Passive ROM

2. Hemiparesis

   1. Active ROM

3. Ataxia

   1. Support patient on initial ambulation, promote assistive device

4. Dysphagia

   1. Aspiration precautions

Cerebrovascular Disorders (Motor Loss as a Clinical Manifestation): Identify the following being described, together with their corresponding nursing management:

1. Paralysis

2. Weakness

3. Unsteady gait; Staggering

4. Difficulty Swallowing

1. Test pharyngeal/gag reflex using tongue depressor

2. Started on THICK liquid diet (Pureed)

3. Upright position and tuck the chin toward the chest then swallow

   1. Pharynx airway = anterior; tucking = closed airway

4. Place food on unaffected side of the mouth

5. Allow ample time to eat

Cerebrovascular Disorders (Motor Loss as a Clinical Manifestation): Discuss what aspiration precaution consists

1. Test _____________ reflex using _____________

2. Started on _____________ diet (_____________)

3. _____________ position and _____________ toward the _____________ then _____________

4. Place food on _____________ side of the _____________

5. Allow _____________ time to _____________

1. Aphasia → Alternative method of communication

   1. Expressive Aphasia

      1. Explore ability to write as alternative (e.g. magic slate, pic board)

   2. Receptive Aphasia

      1. Explore ability to read as alternative

   3. Global Aphasia

      1. Use gestures, actions, or pictures

Cerebrovascular Disorders (Verbal Deficit as a Clinical Manifestation): Identify the following being described, together with their corresponding nursing management:

1. Inability to express or to understand language

   1. Cannot express language

   2. Cannot understand language

   3. Cannot express and understand language

a. Expressive Aphasia

Broca’s Area

a. Expressive Aphasia
b. Receptive Aphasia

b. Receptive Aphasia

Wernicke’s Area

a. Expressive Aphasia
b. Receptive Aphasia

a. Expressive Aphasia

Frontal Lobe

a. Expressive Aphasia
b. Receptive Aphasia

b. Receptive Aphasia

Temporal Lobe

a. Expressive Aphasia
b. Receptive Aphasia

• Allow sufficient time to respond

• Never finish your patient’s sentence

Cerebrovascular Disorders (Verbal Deficit as a Clinical Manifestation): What should you remember as consideration for patients with verbal deficits?

Frontal → Broca → Expressive

Temporal → Wernicke → Receptive

(Repeat)

Now I know that both of them are on the left side of the brain~

BONUS: Sing Ma’am Lorelie’s Song!

Homonymous Hemianopsia

1. Place objects within INTACT field of vision

2. Approach patient on UNAFFECTED side

3. Instruct the patient to scan the AFFECTED side via HEAD TURNING

Cerebrovascular Disorders (Visual Field Deficit as a Clinical Manifestation): Identify the following being described, together with their corresponding nursing management:

1. Loss of half of the visual field

   1. Place objects within ______ field of vision

   2. Approach patient on ______________side

   3. Instruct the patient to scan the _________ side via _____________

Affected side of vision corresponds to the paralyzed side of the body

Ex. Left sided ischemic stroke → Right sided paralysis and Right homonymous hemianopsia

Cerebrovascular Disorders (Visual Field Deficit as a Clinical Manifestation): What is the principle of Homonymous Hemianopsia in relation to paralysis?

Agnosia

• Assist patient in self-care but ensuring to promote independence

Cerebrovascular Disorders (Sensory Loss as a Clinical Manifestation): Identify the following being described, together with their corresponding nursing management:

1. Unable to recognize objects through sensory system (but senses are normal/intact)

Joint deformities/contractures

• When bed rest: Put PILLOW on AXILLA

• Apply SPLINT at NIGHT on AFFECTED extremity

• Reposition q2H

• ROM exercises

Cerebrovascular Disorders (Joint deformities/contractures as a Clinical Manifestation): Identify the following being described, together with their corresponding nursing management:

1. Arm adduct, elbow, and wrist flex.

   1. When bed rest: Put ________ on _______

   2. Apply ________ at __________ on __________ extremity

   3. Reposition q___

   4. ________ exercises

FALSE: When control of voluntary muscle is lost, strong FLEXOR muscles exert control over EXTENSORS

Cerebrovascular Disorders (Joint deformities/contractures as a Clinical Manifestation):

TRUE or FALSE: When control of voluntary muscle is lost, strong extensor muscles exert control over flexors