NUR 331 Adult Health I: Alteration in Neural Functioning – Part 1

Seizure Disorders

- Seizures

- Epilepsy

Seizures

- Episodes of abnormal motor, sensory, autonomic, or psychic activity

- Result from sudden excessive discharge from cerebral neurons

- Can involve localized area or entire brain

Epilepsy

- Defined by the International League Against Epilepsy (ILAE)

- More than one unprovoked seizure

- Differentiates between focal onset, generalized onset, and unknown onset seizures

Focal (Partial) seizures

Originate within a localized area of the brain

Generalized seizures

Engage bilaterally distributed networks rapidly

Unknown onset seizures

Unclassified due to incomplete data

Pathophysiology of Seizures: Electrical disturbance

Abnormal, excessive, uncontrolled electrical activity in brain neurons causes a seize

Causes of seizures

- Varied and categorized

- Genetic

Structural

- Metabolic

- Unknown

Examples of Causes of Sezuires

- Allergies

- Brain tumor

- Cerebrovascular disease

- CNS infections

- Drug and alcohol withdrawal

- Fever (childhood)

- Head injury

- hypertensioN

- hypoxemia

- metabolic conditions

- toxic conditions

CM of Seizures: Seizure range

- From simple staring episodes to prolonged convulsive movements with loss of consciousness

- Initial pattern indicates brain region of seizure origin.

CM of Seizures: Generalized seizures

- Involve both hemispheres, causing bilateral body reactions

- Intense body rigidity followed by alternating muscle relaxation and contraction

- Possible epileptic cry, tongue chewing, incontinence

- Postictal state: Confusion, difficulty arousing, potential sleep for hours

CM of Seizure: Focal seizures

- Subdivided into motor and nonmotor symptoms

- Impairment of consciousness or awareness, localization, and progression of symptoms

Assessment of Seizures

- Identify seizure type

- frequency

- duration

- severity

- triggers.

- Review developmental history

- previous illnesses

- head injuries.

Diagnostic Testing for Seziures

- Laboratory tests

- Identify metabolic, electrolyte, or infectious causes.

- MRI: Detect structural abnormalities or brain lesions.

- EEG: Record abnormal electrical activity and help classify seizures.

- Video EEG monitoring: Correlate seizure activity with clinical manifestations.

- SPECT: Localize seizure focus, primarily for surgical evaluation.

Nursing Care During a Seizure: Observation and documentation

- Sequence of signs before and during seizure

- Circumstances before seizure (stimuli, disturbances, sleep, hyperventilation)

- Occurrence of an aura (premonitory sensation)

- Initial patient actions, movement onset, gaze position, head position

Nursing Care During a Seizure: Seizure details

- Type of movements, areas involved, pupil size, eye position

- Presence of automatisms, incontinence, duration of seizure phases

- Unconsciousness, paralysis, speech ability, movements at seizure end

- Postseizure cognitive status (confusion, sleepiness)

Nursing care of Sezuires

- Prevent injury

- support patient physically and psychologically.

Nursing Care After a Seizure: Documentation

Events leading to, during, and after seizure

Nursing Care After a Seizure: Complication prevention

- Aspiration, injury

- Place patient in side-lying position for oral secretion drainage.

- Perform suctioning if needed to maintain airway.

Nursing Care After a Seizure: Seizure precautions

- Functioning suction equipment

- low bed position

- padded side rails

- Additional safety measures (e.g., padded floor)

Nursing Care After a Seizure: Postseizure care

- Patient may be drowsy

- wish to sleep

- may not remember events

- Ensure patient safety and comfort.

Guidelines for Seizure Care

Status Epilepticus

acute prolonged seizure activity

Status Epilepticus: Goal of treatment

- Stop the seizures as quickly as possible

- Ensure adequate cerebral oxygenation

- Maintain the client in a seizure-free state

Status Epilepticus: Treatment

- IV diazepam, lorazepam, or fosphenytoin given slowly to halt the seizure

- Monitor continuously Vital signs and Neurologic signs

- EEG and ECG monitoring

- Position side-lying, if possible and have suction equipment ready for use

- Protect the client from injury-long term anticonvulsant therapy places the client at risk for fractures

Spinal Cord Injury (SCI)

- Major health disorder caused by trauma to the spinal cord, vertebral column, supporting soft tissue, or intervertebral discs.

- Approximately 305,000 persons in the United States living with SCI

- Estimated 18,000 new cases annually

- Common causes: motor vehicle crashes, falls, violence (predominantly gunshot wounds), and sports-related injuries

- Predominantly affects males (79% of patients)

- Average age of injury: 43 years

- Major risk factors: younger age, male gender, alcohol, and illicit drug use

- Major causes of death: pneumonia, pulmonary embolism (PE), and sepsis

Pathophysiology of SCI

- Severity: Ranges from temporary dysfunction to permanent paralysis.

- Common injury sites: C5-C7, T12-L1.

- Primary injury: Immediate damage from trauma (compression, contusion, or laceration).

- Secondary injury: Progressive damage from edema, hemorrhage, and ischemia; early intervention can limit further injury.

- Primary injury occurs at the time of trauma

- Secondary injury develops afterward and may be minimized with prompt treatment.

Clinical Manifestations of SCI

- Manifestations depend on the type and level of injury.

- Complete spinal cord lesion: loss of sensory and voluntary motor communication, resulting in paraplegia or tetraplegia

- Incomplete spinal cord lesion: some sensory and/or motor fibers preserved below the lesion

- Injuries classified by area of spinal cord damage: central, lateral, anterior, or peripheral

Assessment and Diagnostic Findings of SCI

- Detailed neurologic examination performed

- X-rays (lateral cervical spine x-rays)

- CT scans

- MRI scan, if ligamentous injury is suspected

- Myelogram, if MRI is contraindicated

- Assessment for other injuries, commonly to the head and chest

- Continuous electrocardiographic monitoring for bradycardia and asystole

Emergency Management of SCI

- Immediate management at the scene is critical.

- Rapid assessment, immobilization, extrication, stabilization, and transportation

- Patient immobilized on a spinal board with head and neck in a neutral position

- Transportation to a trauma center with capacity to manage major neurologic trauma

- Prevent further damage by maintaining the patient in an extended position.

- Use of a rotating specialty bed or cervical collar once the extent of injury is determined

Medical Management (Acute Phase) SCI

- Goals: prevent secondary injury, observe for progressive neurologic deficits, and prevent complications

- Resuscitation and maintenance of oxygenation and cardiovascular stability

- New treatment methods and medications continually investigated

- High-dose IV corticosteroids (methylprednisolone sodium succinate) may be prescribed.

- Oxygen given to maintain high PaO2.

- Diaphragmatic pacing for high cervical spine injuries

Skeletal Fracture Reduction and Traction: SQI

- Immobilization and reduction of dislocations, stabilization of the vertebral column

- Accomplished by surgical or nonsurgical interventions

- Cervical fractures reduced with skeletal traction (e.g., skeletal tongs, halo device)

- Traction force exerted along the longitudinal axis of vertebral bodies

- Gradual increase of traction to restore alignment

- Thoracic and lumbar injuries treated with surgical intervention and immobilization with a fitted brace

Spinal Shock

- sudden depression of reflex activity below the level of injury.

- Muscles without sensation, paralyzed, flaccid, reflexes absent

- Hypotension and bradycardia common

- Close observation for early detection of fever due to blocked sympathetic activity

Neurogenic shock

- loss of autonomic nervous system function below the level of the lesion

- Decreases in blood pressure, heart rate, and cardiac output

- Venous pooling and peripheral vasodilation

- Close observation for early detection of fever due to blocked sympathetic activity

Autonomic Dysreflexia

- Acute emergency!

- Occurs after spinal shock has resolved and may occur years after the injury

- Occurs in persons with SC lesions above T6

- Autonomic nervous system responses are exaggerated

- Symptoms include severe pounding headache, sudden increase in blood pressure, profuse diaphoresis, nausea, nasal congestion, and bradycardia

- Triggering stimuli include distended bladder (most common cause), distention or contraction of visceral organs (e.g., constipation), or stimulation of the skin

Nursing Interventions for Autonomic Dysreflexia

- Place patient in seated position to lower BP

- Rapid assessment to identify and eliminate cause

- Empty the bladder using a urinary catheter or irrigate or change indwelling catheter

- Examine rectum for fecal mass

- Examine skin

- Examine for any other stimulus

- Administer ganglionic blocking agent such as hydralazine hydrochloride (Apresoline) IV

- Label chart or medical record that patient is at risk for autonomic dysreflexia

- Instruct patient in prevention and management

Venous Thromboembolism (VTE)

- Potential complication of immobility in SCI patients

- High risk for deep vein thrombosis (DVT) and pulmonary embolism (PE)

- Manifestations of PE: pleuritic chest pain, anxiety, shortness of breath, abnormal blood gas values

- Low-dose anticoagulation therapy within the first 72 hours and for at least 8 weeks

- Use of anti-embolism stockings or sequential pneumatic compression devices (SCDs)

- Routine use of IVC filters not recommended unless thromboprophylaxis has failed

Spinal Cord Injury Nursing Interventions: Airway & Breathing

- Monitor SpO₂

- lung sounds and ABGs

- support coughing

- suctioning and secretion clearance

Spinal Cord Injury Nursing Interventions: Mobility & Alignment

- Maintain spinal precautions

- reposition safely and perform ROM when appropriate.

Spinal Cord Injury Nursing Interventions: Cardiovascular

- Monitor BP and HR

- advance positioning gradually to limit orthostatic hypotension.

Spinal Cord Injury Nursing Interventions: Skin Integrity

- Offload pressure

- reposition regularly

- assess skin in areas of sensory loss.

Spinal Cord Injury Nursing Interventions: Bladder & Bowel

- Manage urinary retention as indicated

- establish a regular bowel program.

Spinal Cord Injury Nursing Interventions: Nutrition & GI

- Support nutrition and hydration

- monitor for distention, constipation or ileus.

Spinal Cord Injury Nursing Interventions: Safety & Sensation

- Assess sensory deficits

- prevent injury and provide prescribed brace or traction care.

Spinal Cord Injury Nursing Interventions: CLINICAL PRIORITY

- Airway and breathing come first

- cervical SCI (especially C3-C5) may impair diaphragmatic function.

Multiple Sclerosis (MS)

- Progressive, immune-mediated disease of the CNS causing demyelination, axonal damage, and plaque formation.

- Affects approximately 1 million Americans.

- Typically diagnosed between ages 20-50; women affected approximately 3 times more often than men.

- Genetic predisposition

- Epstein-Barr virus

- low vitamin D

- smoking

- obesity

- More prevalent in higher-latitude regions.

Process of Demylination

Three main clinical MS phenotypes

- remitting-relapsing (RRMS)

- secondary progressive

- primary progressive (PPMS)

Common Symptoms of MS

- Symptoms vary widely

- fatigue

- muscle weakness

- impaired gait

- sensory loss

- bladder problems

- visual disturbances

Clinical Manifestations of MS

- Fatigue is the most common and disabling symptom

- Worsens throughout the day, exacerbated by heat and humidity

- Pain caused by lesions on sensory pathways.

- Managed with medications, sometimes surgery

- Cognitive and psychosocial problems may occur.

- Memory loss, decreased concentration, emotional lability

- Bladder, bowel, and sexual dysfunction are common.

No cure for MS

- Treatment aims to delay progression

- manage symptoms

- treat exacerbations

Common symptoms requiring intervention in MS

- ataxia

- bladder dysfunction

- depression

- fatigue

- spasticity

Medications for disease modification and symptom management of MS

- Disease-modifying therapies (DMTs) delay disease progression

- Acute exacerbations treated with high-dose corticosteroids

DMTs target various mechanisms.

- T-cell and B-cell depletion

- immunomodulatory actions

- limiting inflammatory cell migration

- DMTs reduce relapse frequency, neurologic deficits, and delay progression.

- Initiated as soon as possible for RRMS patients

Multiple Sclerosis Nursing Interventions: Collaborative Care

- Coordinate PT/OT

- speech therapy

- social work

- home services.

Multiple Sclerosis Nursing Interventions: Activity & Fatigue

- Encourage exercise and stretching

- pace activity and schedule rest

Multiple Sclerosis Nursing Interventions: Bowel & Bladder

- Use scheduled toileting

- bowel routines

- fluids

- fiber

- prescribed medications.

Multiple Sclerosis Nursing Interventions: Swallowing Safety

- Follow swallowing recommendations

- implement aspiration precautions.

Multiple Sclerosis Nursing Interventions: Cognitive Support

- Provide memory aids

- structured routines

- consistent environment

Multiple Sclerosis Nursing Interventions: Temperatur Control

- Avoid overheating and extreme temperatures

- maintain a cool environment

Multiple Sclerosis Nursing Interventions: Mobility & Safety

- Use assistive devices

- fall precautions

- home modifications

Multiple Sclerosis Nursing Interventions: Psychosocial Support

- Promote stress reduction

- coping strategies

- counseling as needed

Multiple Sclerosis Nursing Interventions: GOAL

- Prevent complications

- conserve energy

- maximize independence

- maximize quality of life

Guillain-Barré Syndrome

- Acute, rapid segmental demyelination of peripheral and cranial nerves

- Annual incidence of 1-2 cases per 100,000 people worldwide

- Slightly higher incidence in males; Death occurs in 5%-10% of cases

Guillain-Barré Syndrome Pathophysiology

- Cell-mediated

- humoral immune attack on peripheral nerve myelin proteins

Guillain-Barré Syndrome Clinical Manifestations

- Muscle weakness and diminished reflexes

- Neuromuscular respiratory failure

- Sensory symptoms: paresthesia and pain

- Cranial nerve demyelination and autonomic dysfunction

Guillain-Barré Syndrome Assessment and Diagnostic Findings

- Symmetric weakness

- diminished reflexes

- upward progression of motor weakness

- History of viral illness

- Lumbar puncture with CSF analysis

- Electrophysiology studies

Guillain-Barré Syndrome Medical Management

- Intensive care unit management

- Mechanical ventilation

- Therapeutic plasma exchange or IVIG

- Continuous ECG monitoring for cardiovascular risks

- Supportive care to prevent complications of immobility

Nursing Interventions for the Patient with Guillain-Barré Syndrome: Enhancing physical mobility and prevention of DVT

- Support limbs in functional position

- Passive ROM at least twice daily

- Frequent position changes at least every 2 hours

- Elastic compression hose or sequential compression boots

- Adequate hydration

Nursing Interventions for the Patient with Guillain-Barré Syndrome

- Administer IV and parenteral nutrition as prescribed

- Carefully assess swallowing and gag reflex and take measures to prevent aspiration

- Develop a plan for communication individualized to patient needs

- Decreasing fear and anxiety

Collaborative Problems and Potential Complications of the Patient with Guillain-Barré Syndrome

- Respiratory failure

- Autonomic dysfunction

- DVT

- Pulmonary embolism

- Urinary retention