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BOWEL/BLADDER DYSFUNCTION
THE GOAL OF MANAGEMENT IS GOING TO BE TO CONTROL THE INCONTINENCE IF POSSIBLE AND ESTABLISH SOME
REGULAR ELIMINATION PATTERNS IN THIS CLIENT. THIS IS NOT ALWAYS POSSIBLE, BUT THIS IS WHAT OUR GOAL IS.
BLADDER DYSFUNCTION
IF YOU HAVE A NEW CLIENT THAT COMES IN AND THEY HAVE A HISTORY OR NEW ONSET OF BLADDER DYSFUNCTION,:
- YOU WANT TO DO AN ASSESSMENT OF THEIR VOIDING PATTERNS.
- LOOK AT THINGS THAT MIGHT BE CONTRIBUTING TO THE PROBLEM.
- LOOK AT THE VOIDING PATTERNS, COMPARE THE CURRENT PATTERN TO THE PREVDIOUS PATTERNS AND SEE
WHAT THE CHANGES HAVE BEEN.
- THEY MIGHT BE DOING A URINALYSIS & CULTURE TO LOOK FOR INFECTION.
- ASSESS THE CLIENT’S COGNITIVE FUNCTION – THEIR ABILITY TO KNOW THAT THEY NEED TO VOID.
- PALPATE THEIR BLADDER FOR DISTENTION.
- BLADDER SCAN (AFTER THEY HAVE VOIDED TO SEE IF THEY HAVE RETENTION PROBLEMS)
NEUROGENIC BLADDER – LESION IN NERVOUS SYSTEM THAT STOPS BLADDER FROM WORKING
- ASSESS FOR
O I&O, SHOWS FLUID BALANCE AND KIDNEY FUNCTION
O VOIDING PATTERN, ASK IF IT HAS CHANGED, IF HAD ANY PROBLEMS BEFORE
O LOC, ARE THEY ABLE TO TELL YOU ANYTHING, ARE THEY CONFUSED?
O PALPATE THE BLADDER FOR DISTENSION
RISK FACTORS INCLUDE – BEING NPO FOR LONG PERIOD OF TIME, AND FLUID RESTRICTION. IF THEY HAVE HAD
SURGERY AND HAVE RECEIVED ANESTHETICS (THIS CAN OFTEN TIMES CAUSE URINARY RETENTION. ELDERLY ARE GOING
TO BE AT A GREATER RISK FOR PROBLEMS.
NORMALLY YOUR BLADDER CONTROL IS IN THE SACRAL SEGMENTS OF THE SPINAL CORD (S2 – S4) AND ALSO IN THE
CEREBRAL HEMISPHERE. IN OTHER WORDS, YOU HAVE THAT REFLEX IN THE LOWER MOTOR NEURON THAT EMPTIES YOUR
BLADDER, BUT YOU ALSO HAVE CEREBRAL CONTROL. BOTH OF THESE TOGETHER CAUSE CONTINENCE. YOUR BLADDER
WHEN IT GETS FULL, IF YOU ARE CONTINENT, IT IS NOT GOING TO REFLEXIVELY EMPTY, UNLESS YOU JUST WAIT WAY TOO
LONG. YOU ARE GOING TO BE ABLE TO HOLD IT USING YOUR CEREBRAL UNTIL YOU GET TO THE RESTROOM. IT IS A
COMBINATION OF THOSE TWO THINGS. IF THE PROBLEM IS ABOVE THE T12 (UPPER MOTOR NEURON LESION), YOU ARE
GOING TO LOSE THAT CEREBRAL CONTROL – SO THEY MIGHT LOSE THE URGE TO VOID. IF YOU HAVE AN UPPER MOTOR
NEURON LESION AND THE REFLEX REMAINS INTACT, YOU CAN HAVE RELEXIVE INCONTINENCE. WITH REFLEXIVE
INCONTINENCE, THE BLADDER CONTINUES TO REFLEXIVELY EMPTY, BUT USUALLY WHEN IT GETS REALLY FULL. IF THE
PROBLEM IS BELOW T12 (LOWER MOTOR NEURON LESION), THE REFLEX ARC IS DESTROYED AND YOU CAN HAVE FLACCID
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BLADDER. THE BLADDER BECOMES FLACCID AND IT LOSES TONE. IT WILL DISTEND WITH URINE AND YOU MIGHT HAVE
OVERFLOW INCONTINENCE (WHERE THE URINE JUST LEAKS OUT WHEN THE BLADDER CANNOT HOLD ANY MORE).
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BOWEL DYSFUNCTION
THE GOAL OF MANAGEMENT IS GOING TO BE TO CONTROL THE INCONTINENCE IF POSSIBLE AND ESTABLISH SOME
REGULAR ELIMINATION PATTERNS IN THIS CLIENT. THIS IS NOT ALWAYS POSSIBLE, BUT THIS IS WHAT OUR GOAL IS.
IF YOU HAVE A LOWER MOTOR NEURON LESION, WHAT YOU LOSE IS THE REFLEXIVE EMPTYING OF THE BOWEL. YOU
LOSE THE ANAL SPHINCTER REFLEX AND TONE. WITH LOWER MOTOR NEURON LESIONS YOU MIGHT JUST HAVE A
CONSTANT SEEPING OF FECAL CONTENT. MANY CLIENTS LOWER MOTOR NEURON LESIONS MIGHT HAVE A COLOSTOMY TO
MANAGE THE STOOL.
- ASSESS FOR
O BOWEL SOUNDS IN ALL FOUR QUADRANTS
O LOOK FOR DISTENTION
O CHECK THE COGNITIVE & FUNCTIONAL ABILITY
O LOOK AT PRESENCE OF RISK FACTORS FOR BOWEL DYSFUNCTION THAT THEY MIGHT HAVE. (IMMOBILE OR
NPO OR IF THEY HAVE SOME SPINAL CORD COMPRESSION)
O THERE IS A WAY TO CHECK FOR THE ANAL REFLEX – THIS IS REFERRED TO AS THE ANAL WINK – THIS
MEANS THAT THE ANAL SPHINCTER RELFEX IS INTACT. STROKE THE ANAL AREA AND SEE IF YOU SEE
CONTRACTION OF THE EXTERNAL ANAL SPHINCTER. THIS WILL BE LOST WITH THE LOWER MOTOR
NEURON LESIONS. THE ANAL SPHINCTER SHOULD BE INTACT WITH AN UPPER MOTOR NEURON LESION.
O ANY PREVIOUS PROBLEMS
RISK FACTORS INCLUDE – FLUID RESTRICTION, PROLONGED IMMOBILITY, NPO, ↓ FIBER, AND ALTERED LOC
MANAGEMENT
- CAN DO BOWEL PROGRAMS – IF YOU HAVE A CLIENT THAT HAS BOWEL DYSFUNCTION, THIS IS GOING TO BE A
VERY INDIVIDUALIZED PROGRAM. IF YOU HAVE A CLIENT THAT HAS A LONG HISTORY OF SPINAL CORD INJURY
AND THEY ARE ON THEIR OWN BOWEL PROGRAM, YOU WILL FIND THAT THEY ARE USUALLY VERY RIGID WITH THAT
PROGRAM. THEY DO THE SAME THING AT THE SAME TIME EVERY DAY. THEY HAVE TRAINED THEIR BOWELS TO
EMPTY AT THAT CERTAIN TIME AND THEY CAN GET VERY DISTRESSED IF THIS PROGRAM IS NOT CLOSELY
FOLLOWED. CONSTIPATION CAN BE A BIG PROBLEM FOR A CLIENT WITH A SPINAL CORD INJURY. THIS IS VERY
COMMON WITH PATIENTS THAT HAVE THE UPPER CORD LESIONS THAT STILL HAVE THAT REFLEXIVE EMPTYING
INTACT. THE BOWEL PROGRAMS TEND TO WORK BETTER FOR YOUR UPPER MOTOR NEURON LESIONS.
ALTHOUGH BOWEL RETRAINING CAN BE DONE WITH EITHER, IT JUST WORKS BETTER IF THEY HAVE THAT REFLEX
ARC.
- BOWEL TRAINING MIGHT INVOLVE AN ENEMA EVERY SO OFTEN, POSSIBLY EVERY OTHER DAY. MIGHT BE A
DULCOLAX SUPPOSITORY EVERY MORNING 30 MINUTES AFTER BREAKFAST. OFTEN TIMES YOU WILL SEE THESE
INTERVENTIONS DONE AFTER BREAKFAST BECAUSE THIS MAXIMIZES THE GI MOTILITY.
- CAN ALSO USE DIGITAL STIMULATION IF THE REFLEX ARC IS INTACT (UPPER MOTOR NEURON LESION).
- ALLOW FOR PROPER USAGE AND BARRIER FREE ACCESS OF BATHROOM WHEN NEEDED
- POSITIONING – IF BEDRIDDEN WOULD TURN THE PATIENT ON THEIR SIDE AND FLEX THEIR KNEES TO INCREASE
THE INTRABDOMINAL PRESSURE TO AID WITH DEFECATION.
- TEACHING VALSALVA MANEUVER (UNLESS CONTRAINDICATED)
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MOTOR DYSFUNCTION
- SURPASS ALL OTHER CLINICAL NEURO SYMPTOMS IN FREQUENCY BECAUSE THE NERVOUS SYSTEM IS DESIGNED
FOR MOVEMENT OF BODY IN SPACE
TERMS USED
- PARALYSIS – COMPLETE LOSS OF SENSORY OR MOTOR FUNCTION, NO VOLUNTARY MOVEMENT
- PARESIS – WEAKNESS, LESSER DEGREE OF PARALYSIS, OFTEN TIMES ON ONE SIDE OF THE BODY
MOTOR FUNCTION REFLECTS THE INTEGRITY OF LOTS OF DIFFERENT ASPECTS OF YOUR NEUROLOGIC SYSTEM. IT
INVOLVES THE CORTICOSPINAL TRACT, PYRAMIDAL TRACT (PRYAMID SHAPED BUNDLE OF NERVE FIBERS IN THE MEDULLA
THAT CONTROL MOVEMENT), EXTRAPYRAMIDAL SYSTEM, CEREBELLAR FUCNTIONS. MOTOR FUNCTION AFFECTS EACH
SYSTEM.
MOTOR NEURON DAMAGE – INJURY OR DAMAGE AT ANY LEVEL WILL PRODUCE AN ALTERATION IN MUSCLE STRENGTH,
MUSCLE TONE, AND REFLEX ACTIVITY.
- DEPENDS ON IF UPPER OR LOWER
- THE SPECIFIC MANIFESTATIONS ARE GOING TO DIFFER DEPENDING UPON WHETHER YOU HAVE AN UPPER MOTOR
NEURON LESION OR A LOWER MOTOR NEURON LESION
MUSCLE TO MOVE. THIS IS WHERE THE LOWER MOTOR NEURONS ARE LOCATED. THEY ARE LOCATED IN BOTH
THE CENTRAL NERVOUS SYSTEM AND THE PERIPHERAL NERVOUS SYSTEM.
- THE LOWER MOTOR NEURON IS GOING TO MAKE THE SKELTAL MUSCLE MOVE. REMEMBER THAT THE IMPULSE
CROSSES AT THE MEDULLA. SO IF YOU NEED YOUR RIGHT HAND TO MOVE, IT IS CONTROLLED BY THE LEFT SIDE
OF THE BRAIN. THE IMPULSE CROSSES SIDES.
- IMPULSES THAT BEGIN IN THE LOWER MOTOR NEURONS, GO FROM THE PERIPHERAL NERVE TO THE SKELTAL
MUSCLE, MANY OF THESE LOWER MOTOR NEURON PATHWAYS ARE REFERRED TO AS REFLEX ARCS (DOES NOT
HAVE TO TRAVEL TO THE BRAIN TO MAKE A CONSCIOUS DECISION TO PERFORM AN ACTION – THE KNEE JERK
REFLEX). HAVE REFLEX ARCS IN THE LOWER MOTOR NEURONS. DO NOT HAVE TO MAKE A DECISION FOR
SOMETHING TO HAPPEN, IT HAPPENS IN RESPONSE TO A STIMULUS. TRAVELS THROUGH THAT REFLEX ARC AND
THE LOWER MOTOR NEURONS PUT OUT THE RESPONSE. BECAUSE OF THIS, A PERSON WHO HAS A LOWER
MOTOR NEURON LESION LOSES THE REFLEX ACTIVITY. LOSE THE DEEP TENDON REFLEXES, YOUR BOWEL AND
BLADDER EMPTYING, SEXUAL FUNCTION.
MOTOR ASSESSMENT
- MUSCLE SIZE – USE A TAPE MEASURE AND COMPARE DAILY
- MUSCLE TONE – PALPATE AND OBSERVE THE MUSCLE AT REST OR PASSIVE MOTION (SEE IF IT IS
SYMMETRICAL). SOME ABNORMAL FINDINGS HERE MIGHT BE SPASTICITY (↑ IN MUSCLE TONE WHICH WOULD BE
WITH AN UPPER MOTOR NEURON LESION), RIGIDITY, RESISTENCE TO PASSIVE RANGE OF MOTION OR YOU MIGHT
SEE FLACCIDITY (THIS WOULD BE COMMON IN A LOWER MOTOR NEURON LESION – REFLEX ARC IS LOST)
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- MUSCLE STRENGTH – HAVE PATIENT SQUEEZE FINGERS OR PUSH AGAINST HANDS. YOU CAN DOCUMENT
MUSCLE STRENGTH ON A 0 TO 5 SCALE (5 WOULD BE COMPLETELY NORMAL STRENGTH AGAINST GRAVITY AND
RESISTENCE ALL THE WAY DOWN TO 0 WHERE YOU HAVE NO MOVEMENT).
- COORDINATION – AMBULATE, OR IF ON BEDREST WATCH MOVEMENTS OF HAND WHILE PICKING THINGS UP.
THIS LOOKS AT CEREBELLAR FUNCTION. WATCH FOR GAIT DISTURBANCES. LOOK FOR COORDINATION OF THE
UPPER EXTREMITIES (FINGERS TO THE NOSE). RAPID MOVEMENT OF THE FINGERS OR HANDS.
- BALANCE – EXAMINE WHEN SITTING UP, OR AMBULATING. THIS LOOKS AT CEREBELLAR FUNCTION.
TERM:
- DECORTICATION – INTERNAL ROTATION AND FLEXION OF UPPER EXTREMITIES, AND EXTENSION WITH PLANTER
FLEXION OF LOWER EXTREMIITES
- DECEREBRATION – EXTENTION AND OUTWARD ROTATION OF UPPER EXTREMITIES, AND EXTENSION WITH PLANTAR
FLEXION OF LOWER EXTREMITIES. DECEREBRATION IS THE WORST OF THE TWO.
- TOTAL FLACCIDITY IS THE VERY WORST OF ALL. THEIR REFLEXES ARE ABSENT. THE CLIENT WILL HAVE A “RAG
DOLL” APPEARANCE.
ELDERLY POPULATION (SOME OF THESE THINGS CAN BE RELATED TO AGING AND ARE GOING TO AFFECT OUT
ASSESSMENT OF THE MOTOR SYSTEM)
- FLEXED POSTURE – SLUMPED IS NORMAL
- INSPECT MUSCLE RIGGIDITY OR WASTING
- TREMORS
- SLOWNESS IN MOVEMENT
- DECREASE IN BRAIN WEIGHT (CEREBRAL ATROPHY – ACTUAL SHRINKING OF BRAIN TISSUE)
- LOSS OF NEURONS
- MEMORY LOSS – MAINLY SHORT TERM LOSS
- PUPILLARY RESPONSE SLUGGISH
MANAGEMENT
- ASSESS
- POSITIONING
- CLIENT AND FAMILY TEACHING
- BALANCE
- EXERCISE TO KEEP TONE
- COORDINATION
PEDIATRICS
- INFANTS DO NOT HAVE A COMPLETELY MATURE NEUROLOGIC SYSTEM WHEN THEY ARE BORN. IT IS VERY
IMMATURE.
- AT BIRTH, THEY HAVE VERY UNCOORDINATED AND WEAK MOVEMENTS.
- THEY CAN SHORT CIRCUIT WHEN THEY ARE TOUCHED DUE TO AN INCOMPLETE MYELIN SHEATH. THIS MEANS
THAT YOU MIGHT TOUCH THEIR FOOT AND IT LOOKS LIKE THEY STARTLE ALL OVER. THEY HAVE A SHORT CIRCUIT
OF NERVE IMPULSE ACTIVITY. MYELIN COVERS THE NERVE FIBERS THAT SERVES AS AN INSULATOR AROUND THE
NERVES.
- MYELINIZATION OCCURS FROM TOP TO BOTTOM. THIS IS CALLED CEPHALOCAUDAL AND THEN INNER TO OUTER
WHICH IS PROXIMODISTAL. THIS IS WHY THEY HAVE GROSS MOTOR BEFORE THEY HAVE FINE MOTOR SKILLS.
USUALLY THE MYELINIZATIN IS COMPLETE AT TODDLER HOOD, BUT THEY CONTINUE TO HAVE FURTHER
MYELINIZATION FOR SEVERAL YEARS, SO THEY ARE GOING TO GET EVEN BETTER AT THEIR MOTOR COORDINATION
AS THEY GROW.
- THEY DON’T LOCALIZE REAL WELL. YOU DO NOT SEE A TINY INFANT WITH ANY TYPE OF FINE MOTOR SKILLS.
THIS IS SOMETHING THAT THEY DEVELOP WITH TIME.
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NURSING MANAGEMENT
- FIRST OF ALL ASSESSMENT IS VERY IMPORTANT, ANY CLIENT THAT HAS AN ALTERATION IN PHYSICAL MOBILITY OR
PARALYSIS, THEY ARE GOING TO NEED CAREFUL ATTENTION BY THE NURSE.
- POSITIONING – YOU DO NOT WANT THEM ON THE AFFECTED EXTREMITY FOR TOO LONG. IF THEY HAVE
HEMIPALEGIA, YOU WANT TO LIMIT THE TIME THAT THEY SPEND ON THAT WEAK SIDE BECAUSE MANY OF THEM
HAVE DECREASED SENSATION ON THE AFFECTED SIDE AND THEY CANNOT SENSE PRESSURE BUILDUP OR PAIN.
THEY ARE GOING TO BE AT INCREASED RISK FOR SKIN BREAKDOWN ON THAT WEAKER SIDE. YOU CAN IMPEDE
CIRCULATION AND THEY MAY NOT FEEL IT. REALLY WATCH THAT AFFECTED EXTREMITY.
- THEY ARE AT RISK FOR CONTRACTURES, FOOT DROP, KNEE AND HIP FLEXION, BLOOD CLOTS (ALL OF THE
HAZARDS OF IMMOBILITY).
- SPASTICITY CAN BE REAL PAINFUL, THEY MAY NEED ANTISPASMODICS. THE WILL HAVE SPASTICITY WITH AN
UPPER MOTOR NEURON LESION.
- THESE CLIENTS MAY NEED PASSIVE ROM ON THE AFFECTED SIDE. THEY MIGHT NEED SPLINTS. PROPER
POSITIONING IS VERY IMPORTANT
- TEACH REGARDING HOME CARE
- EMOTIONAL SUPPORT
- IF THEY HAVE ASSISTIVE DEVICES, MAKE SURE THAT THEY UNDERSTAND HOW TO USE THOSE.
- IF YOU DO HAVE A CLIENT WITH MUSCLE WEAKNESS, YOU DO WANT THEM TO PARTICIPTE IN REHAB AND
EXERCISING, BUT YOU DO NOT WANT TO EXERCISE THIS CLIENT TO THE POINT OF FATIGUE. THIS MAY CAUSE
MORE PROBLEMS.
ALTERED COMMUNICATION
- APHASIA IS A DISTURBANCE OF BRAIN CENTER WHICH MAY INVOLVE IMPAIRMENT OF THE ABILITY TO READ AND
WRITE AS WELL AS TO SPEAK, LISTEN, CALCULATE, COMPREHEND, AND UNDERSTAND GESTURES.
- APHASIA IS ALSO REFERRED TO AS THE LOSS OF THE ABILITY TO USE LANGUAGE AND TO COMMUNICATE
THROUGHTS VERBALLY OR IN WRITING. APHASIA IS GOING TO INTERFERE WITH THE ABILITY TO EITHER
UNDERSTAND OR EXPRESS THOUGHTS AND IDEAS.
- USUALLY RESULTS FROM INJURY IN CORTEX OF LEFT HEMISPHERE (SPEECH CENTER), POSTERIOR FRONTAL, OR
ANTERIOR TEMPERAL LOBES – THIS IS WHY YOU OFTEN SEE RIGHT SIDED WEAKNESS AND SPEECH DIFFICULTIES
GOING HAND IN HAND WITH THE CLIENT THAT HAS HAD A STROKE (BECAUSE SPEECH IS CONTROLLED BY THE
LEFT SIDE OF THE BRAIN)
- MAJOR CAUSES: CVA, HEAD INJURY, OR BRAIN TUMOR – DIRECTLY AFFECT THE SPEECH CENTER IN THE
BRAIN,
TERMS:
DYSARTHRIA – IMPAIRED SPEECH DUE TO PARALYSIS OF THE MUSCLES THAT PRODUCE SPEECH. WE NEED OUR JAWS,
TONGUE, ETC. THIS WILL RESULT FROM A STROKE. THIS PERSON KNOWS WHAT THEY WANT TO SAY, THEY ARE TRYING
TO GET IT OUT, BUT THEY CANNOT GET THE MUSCLES TO WORK TO PRODUCE THE WORDS
ATRAXIA – THE INABILITY TO PERFORM A PREVIOULSY LEARNED ACTION. IF YOU ASK THEM TO WAVE GOOD BYE THEY
MAY NOT BE ABLE TO DO THIS. IF YOU HAND THEM A FORK, THEY MAY TRY TO COMB THEIR HAIR WITH IT - MOTOR
ATRAXIA
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ASSESSMENT:
- ASSESS RESPONSE TO OPEN-ENDED QUESTIONS
- ASSESS VOCABULARY, GRAMMER, AND SYNTAX (SENTENCE FORMING)
- ASSESS RESPONSE TO VERBAL INSTRUCTION
- ASSESS RESPONSE TO WRITTEN INSTRUCTION WITH COMPLEXITY
- ASSESS EXPRESSION OF WRITTEN IDEAS (CAN THEY WRITE WHAT THEY WANT TO SAY? IF THEY CAN WRITE
WHAT THEY WANT TO SAY WITHOUT ANY DIFFICULTY, THIS WOULD BE DYSARTHRIA)
EVEN WITH EXPRESSIVE APHASIA, THEY ARE GOING TO HAVE DIFFICULTY FINDING THE WORDS THAT THEY WANT, BUT
THEY MIGHT ALSO HAVE DIFFICULTY WRITING THE WORDS THAT THEY WANT TO WRITE. THEY CANNOT FIND THE WORD IN
THEIR BRAIN. THEY WILL BE ABLE TO USE A COMMUNICATION BOARD EASIER THAN THEY WILL BE ABLE TO TELL YOU
WHAT IS GOING ON, BUT THEY STILL MAY HAVE A LITTLE BIT OF DIFFICULTY.
NURSING DIAGNOSIS
- SENSORY/PERCEPTUAL ALTERATION
- IMPAIRED VERBAL COMMUNICATION
- IMPAIRED MEMORY
NURSING MANAGEMENT
- PROMOTING POSITIVE SELF-ESTEEM
- IMPROVING COMMUNICATION ABILITIES
- INCREASING AUDITORY STIMULATION
- HELPING FAMILY COPE
THEY HAVE A VARIETY OF CLINICAL MANIFESTATIONS AS FAR AS WHAT THE SEIZURE LOOKS LIKE. DEPENDING ON THE
LOCATION OF WHERE THE PROBLEM IS, WHERE THE SEIZURE ACTIVITY STARTED, AND ALSO HOW WIDE THE ACTIVITY WAS
(IF IT WAS CONTAINED IN ONE SMALL PART OF THE BRAIN, YOU MIGHT ONLY SEE ONE SYMPTOM OR ONE EXTREMITY
MOVING. WHEREAS IF THE ENTIRE BRAIN IS INVOLVED, YOU ARE GOING TO SE A LOT MORE MOTOR ACTIVITY).
DEPENDS ON HOW MUCH AND WHAT AREA OF THE BRAIN WAS INVOLVED.
WHEN WE TALK ABOUT CONVULSION DISORDER – WE THINK OF THE EPILEPSIES. THIS IS A DISORDER OF THE BRAIN
FUNCTION THAT IS CHARACTERIZED BY RECURRENT SEIZURES. SO EVERYONE THAT HAS HAD A SEIZURE DOES NOT HAVE
EPILEPSY. THE SEIZURE MIGHT BE AN ISOLATED EVENT. EPILEPSY IS CHARACTERIZED BY RECURRENT SEIZURES.
THE DR. WILL WANT TO KNOW HOW LONG IT LASTED AND WHAT PARTS OF THE BODY WERE EFFECTED
THE ONSET OF EPILEPSY IS USUALLY BEFORE THE AGE OF 20 YRS. IT AFFECTS ABOUT 1% OF ADULTS IN THE UNITED
STATES. USUALLY IT IS THE SYMPTOM OF AN UNDERLYING CONDITION, ALTHOUGH NOT ALWAYS CAN THEY FIND THE
CONDITION THAT HAS CAUSED IT.
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COMPLEX SYMPTOMS
USUALLY THERE IS SOME IMPAIRMENT IN CONSCIOUSNESS
2. GENERALIZED SEIZURES
• GENERALIZED SEIZURE REALLY INVOLVES THE ENTIRE BRAIN. SO YOU ARE GOING TO SEE
BILATERALLY SYMMETRIC MOVMENTS.
• CAN BE CONVULSIVE OR NON-CONVULSIVE, BUT IT INVOLVES THE ENTIRE BRAIN SO THE ENTIRE
BODY IS AFFECTED.
• THERE IS NO LOCAL ONSET
• HAVE BEEN REFERRED TO AS GRAND MAL SEIZURES
• THIS IS WHERE THE CLIENT’S SAFETY IS A BIG CONCERN (WITH THESE BIG GENERALIZED
SEIZURES)
• AIRWAY IS A BIG CONCERN WITH A GENERALIZED SEIZURE
PARTIAL SEIZURES CAN TURN INTO GENERALIZED SEIZURE. NOT EVERYONE THAT HAS PARTIAL SEIZURES IS GOING TO
GO ON TO HAVE A GENERALIZED SEIZURE.
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HAVE:
CONTRACTION OF THE VOLUNTARY MUSCLES
THE BODY STIFFENS
LEGS AND ARMS EXTEND OUT
THE JAW SNAPS SHUT
MIGHT HEAR A SHRILL “EPILEPSY CRY” – FROM AIR BEING FORCED OUT OF THE CHEST
CAVITY
POSSIBLE INCONTINENCE
PUPILS DILATE DURING THE TONIC PHASE
APNEIC – BIG CONCERN AIRWAY
PALE – BIG CONCERN AIRWAY
USUALLY THEY WILL COME OUT OF THIS SEIZURE ON THEIR OWN. WE DO WORRY
ABOUT AIRWAY AND WE DO THINGS WITH POSITIONING TO TRY TO PROTECT THEIR AIRWAY
USUALLY THIS IS TRANSIENT, IT IS SELF LIMITING AND THEY WILL COME OUT OF THE
SEIZURE AND THEY WILL BE O.K.
THERE ARE MEDICATIONS THAT WE GIVE, ESPECIALLY WHEN THE SEIZURE KEEPS
GOING. BUT REALLY OTHER THAN GIVING THEM THE MEDICATIONS TO TRY TO PREVENT
THE SEIZURE, ACTUALLY DURING THE SEIZURE OUR MAIN FOCUS IS GOING TO BE SAFETY
AND AIRWAY.
O CLONIC PHASE – THEY TRANSITION FROM THE TONIC PHASE TO THE CLONIC PHASE.
THEY BEGIN TO HAVE THESE VIOLENT RHYTHMIC MUSCULAR CONTRACTIONS
BEGIN TO HYPERVENTILATE
FACE MAY BECOME CONTORTED
EYES ROLL BACK IN THEIR HEAD
EXCESSIVE SALIVATION (MORE CONCERN WITH AIRWAY)
FROTHING FROM THE MOUTH
PROFUSE SWEATING
RAPID PULSE
MIGHT BE UNCONSCIOUS FOR UP TO 5 MINUTES AFTERWARD WITH THIS TONIC CLONIC
SEIZURE.
O AFTER TONIC-CLONIC PHASE IS OVER WITH AND THE SEIZURE IS BEGINNING TO SUBSIDE:
THEY ARE GOING TO BE UNCONSCIOUS FOR UP TO 5 MINUTES.
THE EXTREMITIES ARE LIMP.
THEIR BREATHING IS QUIET. THEY SHOULD BE BREATHING ON THEIR OWN AT THIS
POINT. AIRWAY AND SAFETY ARE BIG CONCERNS WITH SEIZURES. AFTER THE SEIZURE IS
OVER, YOU EXPECT THEIR BREATHING TO QUIET DOWN AND THEY ARE LIMP.
THEIR PUPILS BEGIN TO RESPOND TO LIGHT.
THEY MIGHT BE VERY CONFUSED AND DISORIENTED.
SOME OF THEM MIGHT EVEN BE COMBATIVE WHEN THEY WAKE UP.
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AGAIN, THEY HAVE AMNESIA, THEY KNOW WHAT HAPPENED TO THEM, THEY JUST DON’T
REMEMBER IT.
THEY MIGHT HAVE A HEADACHE
GENERALIZED MUSCLE ACHING AND FATIGUE (DUE TO ALL OF THE VIOLENT MUSCLE
CONTRACTION AND JERKING)
THEY MIGHT SLEEP VERY DEEPLY FOR SEVERAL HOURS. POST ICTAL (AFTER THE
SEIZURE)
• IMMEDIATE GOAL WITH SEIZURES: CONTROL THE SEIZURES (BY MEDICATION, NOT BY FORCE)
• LONG-TERM GOAL: DETERMINE CAUSE AND TREAT THE CAUSE
O ONE EXAMPLE IS AFTER A BIG GENERALIZED SEIZURE, THE FIRST SEIZURE THAT THEY HAVE
EVER HAD AND THEY ARE DIAGNOSED WITH A BRAIN TUMOR. SO THE BIG GOAL IS CONTROLLING
THE SEIZURE, SO THEY GO ON AND GET THEM ON DILANTIN TO KEEP ANOTHER SEIZURE FROM
OCCURING. BUT THEN WHEN THEY HAVE IDENTIFIED THE CAUSE (THE TUMOR), THEY ALSO WANT
TO START FOCUSING ON THE TREATMENT FOR IT AS WELL.
ASSESSMENT: BRUNNER PG 1874 – WE WANT TO ASSESS AND DOCUMENT ALL OF THESE THINGS
- CIRCUMSTANCES BEFORE THE SEIZURE – WHETHER THEY HAD VISUAL, AUDITORY, OLFACTORY, TACTILE STIMULI
– IF THERE IS SOME KIND OF STIMULUS THAT TRIGGERED THE SEIZURE.
- OCCURRENCE OF AN AURA – THIS IS A LITTLE BIT OF A WARNING BEFORE THE SEIZURE. USUALLY THIS AURA
MIGHT BE SOMETHING VISUAL. IT MIGHT SOME AUDITORY THING LIKE THEY MIGHT HEAR RINGING IN THEIR EARS.
THEY MIGHT HAVE A SMELL THAT THEY CAN’T REALLY DESCRIBE BUT THEY KNOW THAT THEY ARE ABOUT TO
HAVE A SEIZURE.
- FIRST THING DONE IN SIEZURE – LOOK AT THE VERY FIRST THING THAT THE CLIENT DOES - WHERE THE
MOVEMENT OR STIFFNESS STARTS, CONJUGATE GAZE POSITION, AND THE POSITION OF THE HEAD AT THE
BEGINNING OF THE SEIZURE. THIS IS GOING TO HELP PINPOINT THE AREA OF THE BRAIN THAT IS INVOLVED.
- TYPES OF MOVEMENTS IN THE PART OF THE BODY INVOLVED
- ALL OF THE AREAS OF THE BODY INVOLVED - NEED TO REMOVE THE COVERS AND SEE IF THE LOWER
EXTREMITIES ARE INVOLVED IN THE SEIZURE.
- THE SIZE OF BOTH PUPILS. ARE THE EYES OPEN OR CLOSED? DID THE EYES OR HEAD TURN TO ONE SIDE?
- THE PRESENCE OR ABSENCE OF AUTOMATISMS (LIP SMACKING OR REPEATED SWALLOWING)
- INCONTINENCE OF URINE OR STOOL
- DURATION OF EACH PHASE OF THE SEIZURE
- IF THEY WERE UNCONSCIOUS, HOW LONG WERE THEY UNCONSCIOUS?
- MOVEMENTS AT THE END OF THE SEIZURE
- SEE IF THEY HAVE PARALYSIS OR WEAKNESS IN THEIR ARMS AND LEGS
- DO THEY HAVE AN INABILITY TO SPEAK AFTER THESEIZURE.
- WHETHER OR NOT THE PATIENT SLEEPS AFTERWARD
- COGNITIVE STATUS (CONFUSED, NOT CONFUSED) AFTER THE SEIZURE
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- DO NOT TRY TO PHYSICALLY RESTRAIN THE CLIENT WHILE THEY ARE HAVING A SEIZURE. THIS CAN CAUSE
INJURY. GO AHEAD AND LET THEM HAVE THE SEIZURE, WHILE YOU ARE PROTECTING THEIR HEAD AND THEIR
AIRWAY.
- WANT TO TURN THEM ON THEIR SIDE, WITH THEIR HEAD KIND OF FLEXED DOWNWARD, SO THEIR TONGUE CAN
FALL FORWARD. THEY CANNOT SWALLOW THEIR TONGUE. DO NOT INSERT TONGUE BLADES INTO THEIR MOUTH.
WE JUST WANT TO FLEX THEIR HEAD FORWARD AND LET THEIR TONGUE FALL FORWARD SO THAT IT DOESN’T
OCCLUDE THE BACK OF THEIR THROAT.
- IF THERE IS SUCTION AVAILABLE, HAVE IT SET UP NEARBY IF YOU KNOW THAT YOUR CLIENT IS PRONE TO
SEIZURES. SO THAT YOU CAN SUCTION THEIR ORAL AIRWAY IF YOU NEED TO WHEN THEY BEGIN TO SALIVATE
AND FROTH AT THE MOUTH. IF YOU DO NOT HAVE THIS EQUIPMENT, THEN YOU CERTAINLY NEED TO HAVE THEM
ON THEIR SIDE WITH THEIR HEAD LEANING FORWARD SO THAT IT CAN DRAIN OUT OF THE MOUTH. (ONLY IF JAWS
ARE NOT CLENCHED)
- IF PATIENT IS IN BED, REMOVE PILLOWS (FROM UNDER HEAD) AND RAISE SIDE RAILS – REMOVE ANYTHING THAT
COULD IMPEDE THEIR AIRWAY
- IF AN AURA PRECEDES THE SEIZURE, INSERT AN ORAL AIRWAY TO REDUCE THE POSSIBLITY OF THE TONGUE OR
CHEEK BEING BITTEN
- DO NOT ATTEMPT TO PRY OPEN THE JAWS THAT ARE CLENCHED IN A SPASM
TO INSERT ANYTHING. (BROKEN TEETH AND INJURY TO THE LIPS AND TONGUE MAY RESULT FROM SUCH
ACTION)
- NO ATTEMPT SHOULD BE MADE TO RESTRAIN THE PATIENT DURING THE SEIZURE BECAUSE MUSCULAR
CONTRACTIONS ARE STRONG AND RESTRAINT CAN PRODUCE INJURY
NURSING ALERT – NURSES MUST TAKE CARE WHEN ADMINISTERING LAMOTRIGINE (LAMICTAL), AN ANTISEIZURE
MEDICATION. THE DRUG PACKAGING WAS RECENTLY CHANGED IN AN ATTEMPT TO REDUCE MEDICATION ERRORS, AS THIS
MEDICATION HAS BEEN CONFUSED WITH: TERBINAFINE (LAMISIL), LABETALOL HCL (TRANDATE), LAMIVUDINE (EPVIR),
MAPROTILINE (LUIOMIL), AND DIPHENOXYLATE/ATROPINE (LOMOTIL).
DIAGNOSTIC EVALUATION
- DETAILED, ACCURATE CLIENT HISTORY (TO LOOK FOR THE CAUSE)
- IN CHILDREN – DEVELOPMENTAL HISTORY (HOW THEY HAVE DEVELOPED, IF THEY ARE DEVELOPING AS THEY
SHOULD)
- PHYSICAL EXAM
- NEURO EXAM
- BLOOD STUDIES – DEPENDANT ON PROBLEM, LOOK AT TOXICOLOGY SCREENS, LOOK FOR HEAVY METALS, LOOK
AT RENAL FUNCTIONS TO SEE IF RENAL FAILURE MIGHT HAVE BEEN A CAUSE.
- CT SCAN – FOR TUMORS THAT COULD BE CAUSING THE SEIZURES
- MRI – LOOKING FOR STRUCTURAL ABNORMALITIES
- EEG – LOOKS AT THE ELECTRICAL ACTIVITY OF THE BRAIN – IT WILL TELL WHAT TYPE OF SEIZURE IT IS,
POSSIBLY COULD PINPOINT THE ORIGIN OF THE SEIZURE.
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TCA 2
- LUMBAR PUNCTURE – TO LOOK FOR THE CAUSE (FOR INSTANCE INFECTION). A LUMBAR PUNCTURE IS
CONTRAINDICATED IF THERE ARE ANY SIGNS OF INCREASED ICP. USUALLY A LUMBAR PUNCTURE IS NOT DONE
UNTIL THEY HAVE DONE SOME CT SCANS AND A THOROUGH EXAM TO TRY TO RULE OUT ANY INDICATION OF
INCREASED ICP.
ANTICONVULSANT MEDICATIONS
- ALWAYS GIVEN INITIALLY
- MECHANISM IS UNKNOWN
- OBJECTIVE IS TO CONTROL SEIZURES WITH MINIMAL SIDE EFFECTS (USUALLY DO THIS BY USING JUST ONE
SINGLE DRUG AND TITRATE THE DOSE – THIS MAY NOT BE POSSIBLE AND THERE MAY BE CLIENTS ON MULTIPLE
ANTISEIZURE MEDS)
- NOT A CURE BUT A CHEMICAL FORM OF CONTROL
- CLOSE MONITORING OF BLOOD LEVELS (EXCEPT NEURONTIN)
- SUDDEN WITHDRAWEL CAN CAUSE SEIZURES TO INCREASE OR CAN PREIPITATE A SEIZURE
MOST ANTI-CONVULSANT MEDICATIONS ARE METABOLIZED IN THE LIVER AND EXCRETED FROM THE KIDNEYS.
TEACH YOUR CLIENT THAT ILLNESS CAN AFFECT THE EFFECTIVENESS OF THE ANTICONVULSANT. IF THEY HAVE SOME
OTHER TYPE OF ILLNESS, THEY MIGHT BE MORE PRONE TO HAVE A SEIZURE.
SURGICAL MANAGEMENT:
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TCA 2
- MAY BE CONSIDERED IF THE SEIZURES CONTINUE DESPITE ANTICONVULSANT THERAPY. PARTICULARLY IF THEY
ARE HAVING A PARTIAL SEIZURE AND THEY CAN IDENTIFY THE EXACT LOCATION IN THE BRAIN THAT THIS SEIZURE
ACTIVITY IS ORIGINATING FROM. THIS CAN BE VERY EFFECTIVE IN REDUCING SEIZURES. THEY WILL ACTUALLY
DISECT THAT PART OF THE BRAIN TISSUE TO TRY TO GET RID OF THE ELECTRICAL ORIGIN OF THE SEIZURE. UP
TO 50% EFFECTIVE IN STOPPING SEIZURES.
STATUS EPILEPTICUS
- ACUTE AND PROLONGED SEIZURE ACTIVITY
- THIS IS THE KIND OF SEIZURE THAT LASTS OVER 30 MINUTES (2 OR MORE SEIZURES)
- DON’T EVER HAVE A FULL RECOVERY BETWEEN THE SEIZURES
- THE MOST COMMON CAUSE OF THIS IS AN ABRUPT DISCONTINUATION OF MEDICINES. WE DO NEED TO TEACH
OUR CLIENTS THAT THEY CANNOT ABRUPTLY STOP TAKING THIS MEDICATION. IF THEY ARE HAVING SIDE EFFECTS
THAT THEY CANNOT TOLERATE, THEY NEED TO SEE THEIR HEALTH CARE PROVIDER ABOUT CHANGING
MEDICATIONS. STOPPING THESE MEDICATIONS WILL CAUSE SEIZURE ACTIVITY AND CAN TRIGGER THIS STATUS
EPILEPTICUS (WHICH IS LIFE THREATENING).
- STATUS EPILEPTICUS IS TREATED AS A MEDICAL EMERGENCY.
- STATUS EPILEPTICUS CAUSES INCREASED METABOLIC DEMANDS ON THE BODY AND ON THE BRAIN TISSUE.
VIGOROUS MUSCLE CONTRACTIONS THAT CAN INTERFERE WITH THE RESPIRATORY STATUS. CAN DEFINITELY
STOP BREATHING DURING STATUS EPILEPTICUS.
- CAN HAVE RESPIRATORY ARREST
- HYPOXIA – OF ALL OF THE TISSUES, PARTICULARLY BRAIN TISSUE. IF HAVE HYPOXIA, YOU HAVE VASODILATION
IN THE BRAIN (CAN GET INCREASED ICP).
- IF HAVE REPEATED EPISODES OF THIS, YOU CAN HAVE CEREBRAL EDEMA AND POSSIBLY IRREVERSIBLE BRAIN
DAMAGE.
- CARDIOVASCULAR OR RESPIRATORY COMPROMISE CAN BE LIFE THREATENING AND CAN LEAD TO INCREASED
CEREBRAL EDEMA. (INCREASED ICP)
NURSING MANAGEMENT:
- SAME SEIZURE SAFETY MEASURES AS LISTED ABOVE (ABC’S ARE PRIORITY)
- WANT TO GET AN IV LINE IN THIS PERSON.
- FREQUENT VITAL SIGNS
- FREQUENT NEURO CHECKS
- LAB WORK
- WANT TO GIVE THEM A FAST ACTING MEDICATION TO STOP THE SEIZURE (ATIVAN, VALIUM). MIGHT SEE THEM
HANG CEREBYX IV IN THE HOSPITAL.
- THERE ARE OTHER DRUGS THAT ARE GIVEN LATER TO TRY TO MAINTAIN A SEIZURE FREE STATE
- THESE CLIENTS MIGHT NEED TO BE INTUBATED TO PROTECT THEIR AIRWAY.
- ANYBODY WITH A SEIZURE DISORDER NEEDS TO WEAR A MEDIC ALERT BRACELET.
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TCA 2
- TEACH THE CLIENT NOT TO PARTICIPATE IN ANY ACTIVITY THAT IS GOING TO CAUSE HARM TO THEMSELVES OR
SOMEONE ELSE IF THEY EVER HAVE A SEIZURE. IF THEIR SEIZURES ARE NOT UNDER CONTROL, THEN THEY DO
NOT NEED TO DRIVE, SWIM, OPERATE HEAVY EQUIPMENT, ETC.
- EDUCATE THE CLIENT AND THE FAMILY ABOUT WHEN TO CALL 911
- EDUCATE ABOUT MEDICATIONS
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TCA 2
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TCA 2
INTRACRANIAL SURGERY’S
- MIGHT UNDERGO IF THE CLIENT HAS A HEMORRHAGE, A TUMOR OR SOMETHING ELSE THAT NEEDS TO BE
REPAIRED WITHIN THE CRANIAL VAULT.
- BURR HOLES – HOLE MADE IN CRANIUM/SKULL TO ACCESS BRAIN TISSUES
O BURR HOLES ARE DONE PARTICULARLY TO EVACUATE BLEEDS OR BLOOD CLOTS.
O IF YOU HAVE A CLIENT WITH A SUBDURAL HEMATOMA THAT COMES IN, THEY CAN DO BURR HOLES TO
IMMEDIATELY RELIEVE THE INCREASED INTRACRANIAL PRESSURE AND REMOVE THAT CLOT AND CONTROL
BLEEDING.
- CRANIOTOMY – SURGICAL OPENING OF THE SKULL
O OFTEN TIMES CLIENTS WILL HAVE CRANIOTOMY SURGERY WHERE THEY WILL ACTUALLY CUT A PIECE OF
THE SKULL OUT AND EXPOSE THE BRAIN TISSUE AND THEN REPLACE IT AS SOON AS THEY ARE DONE
WITH THE SURGERY. THEY MAY USE PLATES OR SCREWS. THEY WILL HAVE AN INCISION OFTEN TIMES
REFERRED TO AS A “HORSE SHOE” INCISION. IT CAN OCCUR DEPENDING UPON THE LOCATION OF THE
SURGERY ANYWHERE ON THE SKULL.
- CRANIECTOMY – EXCISION OF PORTION OF SKULL AND THEY DO NOT REPLACE THAT PART OF THE SKULL.
O SOMETIMES DONE TO ALLOW FOR EXPANSION – IF YOU HAVE SOMEONE WITH SEVERE CEREBRAL
EDEMA. THEY WILL REMOVE A PART OF THE SKULL SO THAT THERE IS A PLACE FOR THE SWELLING TO
GO.
O USUALLY THE CLIENTS THAT HAVE CRANIECTOMIES ARE GOING TO BE IN THE ICU BECAUSE THEY ARE
MISSING A PART OF THEIR SKULL. THE SKULL PROTECTS THE BRAIN. THESE CLIENTS WILL HAVE THIS
BIG AREA WITH JUST SKIN AND SOFT TISSUE COVERING THE BRAIN. THEY CALL THE SECTION THAT THEY
TAKE OUT A BONE FLAP. THE BONE FLAP MIGHT BE SURGICALLY IMPLANTED IN THE ABDOMEN TO KEEP
IT IN A STERILE PLACE AND PRESERVE IT UNTIL IT IS TIME TO GO AND REPLACE IT BACK. SOMETIMES
THEY WILL FREEZE THE BONE FLAPS, OR SOMETIMES THEY WILL USE SOME TYPE OF ARTIFICIAL
MATERIAL TO COVER THE HOLE.
- CRANIOPLASTY – PLASTIC REPAIR OF SKULL
LOCATIONS
- SUPRATENTORIAL – ABOVE THE TENTORIUM (THE TENTORIUM IS THE THICK FOLDS IN THE DURA AT THE BASE OF
THE CEREBRUM), INCLUDES CEREBRUM
- INFRATENTORIAL – BELOW TENTORIUM, BRAIN STEM/CEREBELLUM (CEREBELLUM IS RESPONSIBLE FOR
COORDINATION/BALANCE)
O IF YOU HAVE SOMEONE WITH CEREBELLAR SURGERY, YOUR NAUSEA AND VOMITING CENTERS ARE DOWN
THERE AT THE BASE OF THE BRAIN. SO SOMEONE WITH INFRATENTORIAL SURGERY IS VERY LIKELY TO
BE NAUSEATED, DIZZY, HAVE GAIT AND BALANCE DIFFICULTIES.
PREOPERATIVE CARE
- RADIOLOGIC STUDIES – TO IDENTIFY WHATEVER IT IS THAT THEY ARE DOING THE OPERATIVE PROCEDURE FOR,
WHETHER IT BE A TUMOR OR A HEMORRHAGE
- MEDICATIONS
O ANTICONVULANTS (PROPHALACTIALLY BEFORE THEY EVER HAVE A SEIZURE)
O CORTICOSTEROIDS – TO REDUCE CEREBRAL EDEMA
O OSMOTIC DIURETICS – IF THERE IS A PROBLEM WITH INCREASED ICP - WILL SEE THEM
PREOPERTIVELY ON OSMOTIC DIURETICS OR LOOP DIURETICS OR BOTH TO TRY TO DEHYDRATE THE
BRAIN TISSUE. THIS WILL GIVE THEM A LITTLE EXTRA ROOM FOR THE CEREBRAL EDEMA THAT IS
PROBABLY GOING TO HAPPEN AFTER SURGERY. AFTER SURGERY THERE WILL BE SWELLING.
- A GOOD BASELINE ASSESSMENT IS NEEDED SO THAT YOU KNOW WHAT THE CLIENT’S CONDITION WAS PRE-
OPERATIVELY – SO YOU CAN COMPARE IT TO THEIR POST-OP STATUS. BECAUSE NOT ALWAYS DOES THE CLIENT
COME OUT OF NEURO SURGERY IN BETTER CONDITION PHYSICALLY THAN THEY WENT IN. SOMETIMES THEY
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TCA 2
MIGHT HAVE A STROKE DURING SURGERY. THEY MIGHT HAVE BRAIN TISSUE DAMAGE (FOR INSTANCE IF THEY
WERE REMOVINGA TUMOR). THEY MIGHT HAVE TO GET SOME OF THE GOOD BRAIN TISSUE OUT IN ORDER TO
EXCISE THE TUMOR. THEY MIGHT COME BACK WITH HEMIPAREGIA WHEN THEY WERE JUST HAVING SOME
HEMIPARESIS PRE-OPERATIVELY.
- SHAMPOO AND SHAVE
- FAMILY AND PATIENT COPING
- SUPPORT FOR PATIENT AND FAMILY
- PREPARATION OF THE CLIENT AND THE FAMILY
O GIVE REALISTIC EXPECTATIONS
O NEURO CLIENT IS PROBABLY GOING TO BE GOING TO ICU AFTER SURGERY.
THEY MIGHT HAVE BEEN
ON THE NEURO FLOOR PRE-OP, BUT YOU NEED TO PREPARE THE FAMILY FOR. THE CLIENT WILL HAVE A
BIG TURBAN DRESSING ON THE HEAD. EXPLAIN THE ALL OF THE DRESSING IS NOT FROM THE INCISION.
THIS CLIENT WILL HAVE ARTERIAL LINES. THERE WILL BE FOLEY CATHETERS. THIS PATIENT WILL HAVE
MANY LINES AND TUBES TO MONITOR THEIR CONDITION. IT IS IMPORTANT TO PREPARE THE FAMILY FOR
THESE THINGS.
POSTOPERATIVELY
- CONTINUOUS MONITORING
O BOWEL SOUNDS
O OXYGENATION
O RESPIRATORY STATUS
O IF THEY DEVELOP HYPERTHERMIA, ESPECIALLY RIGHT AFTER SURGERY – THIS MAY INDICATE SOME
PRESSURE OR SOME DAMAGE TO THE HYPOTHALMUS (TEMPERATURE REGULATING CENTER OF THE
BRAIN). YOU DO NOT IMMEDIATELY SEE SIGNS OF INFECTION, SO THINK MORE INTERMS OF THE
ABOVEMENTIONED.
O ASSESS THE OPERATIVE SITE
O MIGHT HAVE AN ARTERIAL LINE OR A CBT LINE, THIS PATIENT MIGHT BE INTUBATED DEPENDING UPON
WHAT THEIR RESPIRATORY STATUS IS.
- FREQUENT NEURO CHECKS
O WE WANT TO GET A BASELINE VERY QUICKLY AND COMPARE IT TO OUR PRE-OP ASSESSMENT. CHECK
THE CHART AND SEE WHAT THE BASELINE WAS BEFORE SURGERY IF YOU DID NOT DO THE PRE-OP
NEURO ASSESSMENT. ASSESS FREQUENTLY AFTERWARDS FOR CHANGES.
- DO NOTHING TO INCREASE ICP
- REDUCE CEREBRAL EDEMA
O CEREBRAL EDEMA AFTER CRANIAL SURGERY PEAKS AT ABOUT 24 TO 36 HOURS.
O TO TREAT CEREBRAL EDEMA:
• ELEVATE THE HEAD OF THE BED
• GIVE DECADRON, MANNITOL
- IN RELIEVING PAIN AND PREVENTING SEIZURES
O HEADACHE IS COMMON AFTER SURGERY, NOT BECAUSE THE BRAIN ITSELF IS SENSITIVE TO PAIN, BUT
ALL OF THE VESSELS THAT ATTACH THE SCALP TO THE UNDERLYING TISSUES AND ALL OF THE BLOOD
VESSELS AND NERVE ENDINGS ARE SENSITIVE TO PAIN. SO THIS CLIENT WILL HAVE HEADACHES FROM
THAT.
O MIGHT GIVE THIS CLIENT CODEINE OR ANTI-INFLAMMATORIES. IF THEY HAVE INCREASED ICP OR ANY
CONCERNS LIKE THAT, THEN WE ARE NOT GOING TO GIVE THIS PATIENT ANY TYPE OF RESPIRATORY
DEPRESSANTS IMMEDIATELY AFTER THE SURGERY. THIS IS REALLY TALKING ABOUT THE ACUTE STAGES
RIGHT AFTER SURGERY. ONCE THE CLIENT IS STABILIZED THE CLIENT MIGHT BE PRESCRIBED MORPHINE
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TCA 2
IM AND THE RISK FOR CEREBRAL EDEMA IS DECREASING. IN GENERAL DON’T GIVE RESPIRATORY
DEPRESSANTS, ESPECIALLY IMMEDIATELY POST-OP.
- DILANTIN IS OFTEN GIVEN, ESPECIALLY WITH SUPRATENTORIAL SURGERY (THEY ARE AT AN INCREASED RISK FOR
SEIZURES).DILANTIN SEEMS TO BE A FAVORITE BECAUSE IT DOES NOT HAVE THE SEDATIVE EFFECT THAT SOME
OF THE OTHER ANTICONVULSANTS DO. IT DOES HAVE SOME, BUT THEY DON’T SEEM TO BE AS SEVERE.
THEREFORE, THE CLIENT IS A LITTLE BIT MORE ALERT.
O NEED TO MONITOR THE SERUM LEVELS
- MONITOR INTRACRANIAL PRESSURE
O THE CLIENT MAY OR MAY NOT HAVE AN INTERNAL ICP MONITOR. IF THEY DO HAVE ONE, THIS WILL BE
DONE IN ICU.
O SIGNS AND SYMPTOMS OF INCREASED ICP
• VITAL SIGNS (SYSTOLIC BLOOD PRESSURE WILL GO UP, WHILE DIASTOLIC PRESSURE REMAINS
THE SAME, THE PULSE IS GOING TO SLOW DOWN),
• MIGHT SEE PUPILLARY CHANGES
• MIGHT SEE RESPIRATORY IRREGULARITIES
• THE VERY FIRST SIGN OF COMPLICATIONS IS AN ALTERATION IN LOC
- POSTITIONING (THIS WILL VARY, DEPENDING UPON WHICH TYPE OF SURGERY THAT THEY HAVE HAD)
O SUPRATENTORIAL SURGERY
• HEAD OF BED RAISED 30° TO 45°
• POSITION THIS CIENT ON THEIR BACK AND ON THE UNOPERATIVE SIDE.
• CAN HAVE A PILLOW UNDER THEIR HEAD AND SHOULDERS
O INFRATENTORIAL SURGERY (NEAR THE CEREBELLUM, MEDULLA AND THE PONS)
• TEND TO BE MORE NAUSEATED AND HAVE A BIT MORE TROUBLE WITH DIZZINESS.
• HEAD OF THE BED WILL BE KEPT FLAT AT FIRST (IMMEDIATELY POSTOP). THE NEUROSURGEON IS
GOING TO DICATE WHEN WE ARE GOING TO RAISE THE HEAD OF THE BED. WE ARE GOING TO
GRADUALLY RAISE IT LATER.
• WE ARE GOING TO POSITION THIS CLIENT FROM SIDE TO SIDE – BECAUSE INFRATENTORIAL
SURGERY IS DONE AT THE NAPE OF THE NECK AND THE BASE OF THE SKULL. SO WE DO NOT
WANT TO LIE THIS CLIENT ON THEIR BACK.
• CAN USE A VERY SMALL, FIRM PILLOW UNDER THEIR HEAD.
O CRANIECTOMY
• THEY NEED A SIGN AT THE HEAD OF THE BED IF THEY HAVE A BONE FLAP MISSING. WE WOULD
NOT PLACE THIS PATIENT ON THE OPERATIVE SIDE.
NURSING MANAGEMENT
- FREQUENT NEURO AND VITAL SIGN ASSESSMENT(TO LOOK FOR THOSE EARLY CHANGES THAT MAY INDICATE
PROBLEMS)
- ASSESS THE DRESSING
O THE DRESSING SHOULD BE DRY. THERE MIGHT BE A SMALL AMOUNT OF DRAINAGE THERE, BUT IT
SHOULD NOT BE WHERE YOU WOULD HAVE TO CHANGE THE DRESSING. IF THEY HAVE ANY KIND OF
DRAINAGE THAT IS EXCESSIVE COMING FROM THIS DRESSING IS A CAUSE FOR CONCERN. IF THE
DRAINAGE IS CLEAR, WE NEED TO BE WORRIED ABOUT CEREBRAL SPINAL FLUID. IF IT IS A LITTLE BIT
BLOODY AND WE SEE SOME YELLOWISH LOOKING DRAINAGE, THIS IS ALSO INDICATIVE OF CSF.
PURULENT DRAINAGE AFTER A DAY OR TWO WOULD BE AN INDICATION OF INFECTION.
- MONITOR FOR A THROMBUS
O THIS CLIENT IS GOING TO BE IMMOBILE AND AT AN INCREASED RISK FOR CLOTS (RIGHT AT FIRST)
- SKIN CARE
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TCA 2
- POSITIONING
- TURNING
- ROM
- SAFETY PRECAUTIONS, INCLUDING SEIZURE PRECAUTIONS (PARTICULARLY WITH THE SUPRATENTORIAL SURGERY)
- SELF CARE ACTIVITIES AS THEY ARE ABLE TO DO FOR THEMSELVES
O IF THEY HAVE INCREASED ICP AND WE HAVE THEM ON ABSOLUTE BEDREST AND DECREASED STIMULI,
THEN WE ARE CERTAINLY NOT GOING TO HAVE THEM PARTICIPATING IN THEIR OWN SELF CARE. AS
SOON AS THEY ARE STABLE ENOUGH, THEN WE WILL.
- MONITOR I&O’S
O TO LOOK SIADH AND DIABETES INSIPIDUS BECAUSE THERE IS POTENTIAL FOR INCREASED ICP.
PARTICULARLY WITH TRANSPHENOIDAL SURGERY.
- MONITOR LAB WORK
O LOOKING FOR INFECTION
O LOOKING FOR ELECTROLYTE IMBALANCES
- MANAGE THEIR SENSORY DEPRIVATION
O THIS CLIENT MIGHT BE INTUBATED, THEY VERY LIKELY WILL HAVE SOME PERIORBITAL EDEMA
(ESPECIALLY ON THE OPERATIVE SIDE) – THEY MIGHT HAVE A BLACK EYE AND IT MIGHT BE SWOLLEN
SHUT, THERE IS NOT VERY MANY PLACES FOR THIS EXCESS FLUID TO DRAIN SO IT CAN DRAIN DOWN
AROUND THE EYE SOCKET AND CAUSE PERIORBITAL EDEMA.
O IF THEY HAVE TURBAN DRESSING THAT IS COVERING THEIR EARS AND THEY WERE ALREADY HARD OF
HEARING. THIS MIGHT BE ANOTHER THING THAT WE NEED TO ADDRESS.
O THEY ARE ISOLATE IN THE ICU
- MONITORING FOR POTENTIAL COMPLICATIONS
O RISK FOR INFECTION
O SHOCK
O INCREASE ICP (RELATED TO SWELLING)
O RISK FOR HEMORRHAGE
O RISK FOR SEIZURES
O PROBLEMS RELATED TO IMMOBILITY
POSTOPERATIVE COMPLICATIONS
- SHOCK – LOSS DURING SURGERY OF BLOOD, RESTLESSNESS (1ST SIGN)
- INCREASED INTRACRANIAL PRESSURE – NO STRAINING, BENDING, ETC…
- CEREBRAL EDEMA
- RESPIRATORY COMPLICATIONS
- CONVULSIONS
- MENINGITIS
- WOUND INFECTION
- DIABETES INSIPIDUS – HOURLY URINE CHECKS
- INAPPROPRIATE SECRETION OF ADH (SIADH) – WILL SEE ↑ NA LVLS, ↓ SPECIFIC GRAVITY, ↑ URINE OUTPUT
- LOSS OF CORNEAL REFLEX – TOO MUCH ADH, FLUID OVERLOAD, ↓ NA, ↑ SPECIFIC GRAVITY, ↓ URINE
OUTPUT
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TCA 2
• POSITION OF HEAD AND BED ELEVATED 30- • POSITIONING – FLAT WITH SMALL PILLOWS UNDER
45 DEGREES NECK.
• TURNING THE PATIENT EITHER SIDE OR • TURNING – EITHER SIDE. SOME DR. DO NOT ALLOW
BACK DO NOT TURN TO OPERATIVE SIDE PATIENT ON BACK
• ELIMINATION – FOLEY CATHETER AND CARE • ELIMINATION – FOLEY CATHETER AND CARE BID.
BID. WATCH FOR S/S OF DIABETES INSIPIDUS. WATCH FOR S/S OF DIABETES INSIPIDUS. ADMINISTER DAILY
ADMINISTER DAILY STOOL SOFTNER TO AVOID STOOL SOFTNER TO AVOID VALSALVA’S MANEUVER
VALSALVA’S MANEUVER
TRANSSPHENOIDAL SURGERY
1) PITUITARY SURGERY
2) MICROSURGERY
3) INCISION IS MADE ABOVE THE GUM. THEY GO UP UNDER THE TOP LIP AND MAKE AN INCISION ABOVE THE GUM,
INSIDE THE MOUTH. THEY USE A DEVICE TO GAIN ACCESS TO THE AREA THAT THEY ARE WORKING ON. THERE
IS A GOOD PICTURE IN BRUNNER.
NURSING CARE
1) MONITOR NEURO STATUS
2) MONITOR VITAL SIGNS
3) MONITOR NASAL PACKING CSF LEAKAGE AND MONITOR PATIENT FOR COMPLAINT OF POSTNASAL DRIP OR
FOR
CONSTANT SWALLOWING. THEY WILL USUALLY COME BACK WITH NASAL PACKING WHEN THEY COME BACK
FROM TRANSSPHENOIDAL SURGERY. DON’T EVER TAKE THE PACKING OUT OF THE NOSE. IF THEY ARE
HAVING SOME DRIPPING OR DRAINAGE AND THE DRESSING IS COMPLETELY SATURATED, NOTIFY THE DOCTOR
AND LET HIM KNOW THAT IT NEEDED TO BE CHANGED OR PACKED SOME MORE. CAN DO A MUSTACHE
DRESSING ON THE UPPER LIP TO CATCH THE DRAINAGE, BUT NEVER PULL THE PACKING OUT OF THE NOSE.
4) MONITOR FOR A CSF LEAK, IF THIS CIENT IS CONSTANTLY SWALLOWING. THEY MAY HAVE SOME CSF
DRIPPING DOWN THE BACK OF THEIR THROAT IN THE NASOPHARNYX AND THE OROPHARNYX. IF IT IS DRIPPING
FROM THE NOSE, THIS WILL OF COURSE INDICATE CSF LEAKAGE. THEY MIGHT DEVELOP A HEADACHE THAT
IS WORSE WHEN THEY SIT UP, VERY SIMILAR TO THE HEADACHES THAT YOU GET AFTER HAVING AN EPIDURAL
IN CHILDBIRTH. WHEN YOU HAVE A LITTLE EXTRA CSF REMOVED, YOU BEGIN TO DEVELOP A HEADACHE
THAT BECOMES WORSE WHEN THEY SIT UP. THESE ARE ALL INDICATIONS OF A CSF LEAK.
5) MONITOR I&O AND LABS CLOSELY (SPECIFIC GRAVITY) – THEY ARE AT RISK FOR DIABETES INSIPIDUS AND FOR
SIADH.
• WITH DIABETES INSIPIDUS, THE URINE OUTPUT WOULD BE INCREASED AND THE SERUM SODIUM WILL
BE INCREASED
• WITH SIADH, THE URINE OUTPUT IS DECREASE AND THE SERUM SODIUM WILL GO DOWN (MORE
HEMODILUTED)
6) NOTE COMPLAINTS OF EXTREME THIRST
7) FREQUENT MOUTH CARE – NO TOOTHBRUSHING – USE A SALINE RINSE
8) NO STRAWS. FIRST OF ALL THEY HAVE THE INCISION ON THE UPPER GUM AND THEN YOU DO NOT WANT TO
CREATE THAT SUCTION EITHER.
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TCA 2
9) NO NOSE BLOWING, COUGHING OR SNEEZING, BEND OR STRAIN FOR A MONTH AFTER NASAL PACKING REMOVED
(ALL OF THESE THINGS CAN CAUSE A CSF LEAK). THIS CAN DISRUPT THE INCISION THAT HAS BEEN MADE.
10)NASAL SPECULUM AND LONG FORCEPS READILY AVAILABLE
11)HIGH FOWLER’S POSITION – TO DECREASE ICP, VENOUS DRAINAGE FACILITATED
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