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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.

THE DIFFERENT CAUSES FOR INCONTINENCE (BLADDER/BOWEL DYSFUNCTION)


- NEUROLOGICAL IMPAIRMENT, SUCH AS A SPINAL CORD INJURY THAT HAS AFFECTED THE REFLEX ARC FOR BOWEL
AND BLADDER EMPTYING. THEY MAY HAVE HAD A STROKE THAT IS AFFECTING THE CEREBRAL CONTROL OF
VOIDING. OTHER EXAMPLES ARE THINGS LIKE PARKINSON’S DISEASE, MULTIPLE SCLEROSIS, OR ANY TYPE OF
NERVE DAMAGE.
- COGNITIVE IMPAIRMENT OR CONFUSION – CLIENTS THAT ARE COGNITIVELY IMPAIRED MIGHT NOT RECOGNIZE THE
URGE TO VOID (FOR INSTANCE IF THEY HAVE HAD A CVA OR A HEAD INJURY). THEY ARE NOT GOIN GTO BE
ABLE TO KNOW THAT THEY NEED TO VOID.
- MOBILITY OR FUNCTIONAL IMPAIRMENT – THEY MAY NOT BE ABLE TO GET TO THE TOILET BECAUSE OF
IMMOBILITY. THEY MAY NOT BE ABLE TO COMMUNICATE TO YOU THAT THEY NEED TO VOID, THEY MAY KNOW IT ,
BUT MIGHT HAVE A COMMUNICATION PROBLEM AND BE UNABLE TO TELL YOU.

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).

NURSING DIAGNOSIS IS RELATED TO ASSESSMENT DATA


- INCONTINENCE (3 TYPES)
O REFLEX – DUE TO SPINAL CORD LESION
O FUNCTIONAL – CAUSED BY ↓ MOBILITY, FUNCTIONAL BARRIERS, ENVIRONMENTAL BARRIERS OR
COGNITIVE PROBLEMS. THERE MAY BE OBSTACLES IN THE WAY OF THE PERSON SO THEY CANNOT GET
UP AND GO TO THE BATHROOM.
O TOTAL INCONTINENCE – UNABLE TO CONTROL EXTRETA DUE TO PHYSIOLOGIC AND PSYCHOLOGICAL
IMPAIRMENT. IF YOU HAVE SOMEONE WITH TOTAL INCONTINENCE, THEY HAVE NO URGE TO VOID. THEY
HAVE LOST THEIR PHYSIOLOGIC MEANS TO VOID. WE ARE GOING TO FOCUS ON:
• MANAGING THE EXCREMENT

• TAKING CARE OF THEIR SKIN

NURSING MANAGEMENT OF BLADDER DYSFUNCTION:


- BLADDER RETRAINING – THIS WILL NEED THE PATIENT TO BE ACTIVELY INVOLVED AND COOPERATING. YOU
HAVE SCHEDULED VOIDING TIMES. THEY WILL BE OFTEN AT FIRST. MAY WANT TO INCREASE FLUIDS UNLESS
CONTRAINDICATED. GIVE POSITIVE REINFORCEMENT. THIS WORKS MUCH BETTER IF THE REFLEX ARC IS INTACT
(UPPER MOTOR NEURON LESION). GET THIS PATIENT ON A REGULAR VOIDING SCHEDULE.
- TEACH THE CLIENT WAYS TO STIMULATE THE BLADDER EMPTYING REFLEX – SUCH AS STROKING THE THIGH,
PULLING A PUBLIC HAIR.
- INDWELLING CATHETER INSERTION AND CARE (PUTS CLIENT AT RISK FOR INFECTION - UTI)
- INTERMITTENT CATHETER IZATION MAY BE NEEDED (PARTICULARLY WITH A LOWER MOTOR NEURON LESION
WHERE THEY HAVE LOST THE REFLEX ARC AND IT IS NOT GOING TO REFLEXIVELY EMPTY). MIGHT HAVE TO
TEACH THE CLIENT TO INTERMITTENTLY CATH SELF. WE WILL TEACH THEM CLEAN TECHNIQUE FOR AT HOME.
DEFINITELY WILL TEACH THEM HANDWASHING AND HOW TO CLEAN THEIR CATHETERS. THEY MAY REUSE
CATHETERS AT HOME.
- CONDOM CATHETERS IF THEY HAVE TOTAL INCONTINENCE.
- INCREASING FLUIDS. NEVER RESTRICT FLUIDS JUST TO RESTRICT THE AMOUNT OF FLUIDS THAT THEY ARE
PUTTING OUT. ONE THING THAT YOU MIGHT DO IS GIVE MOST OF THEIR FLUIDS EARLY IN THE DAY AND YOU
MIGHT BACK OFF FLUIDS AFTER A CERTAIN TIME AT NIGHT SO YOU DO NOT HAVE AS MUCH PROBLEM AT NIGHT.
- CREDE’ MANEUVER (APPLICATION OF PRESSURE OVER THE LOWER ABDOMEN) MAY BE USED IF YOU HAVE
SOMEONE WITH A FLACCID BLADDER (LOWER MOTOR NEURON LESION). INCREASE THE INTRA-ABDOMINAL
PRESSURE – HAVE THEM LEAN OVER. YOU MIGHT GET THE BLADDER TO EMPTY SOME DOING THIS BY GOING
AHEAD AND OPENING THAT SPHINCTER UP. USUALLY IF THE CLIENT HAS LOST THE REFLEX ARC, YOU ARE GOING
TO NEED INTERMITTENT CATHETERIZATION. NOT GOING TO BE ABLE TO EFFECTIVELY COMPLETELY EMPTY THE
BLADDER USING THE CREDE MANEUVER.
- PROVIDE PRIVACY TO THIS CLIENT WHILE TRYING TO VOID
- PROVIDE A BARRIER FREE ACCESS TO THE TOILET
- MODIFY THE CLOTHING (POSSIBLE ELASTIC WASTEBANDS) TO HELP MAKE VOIDING EASIER.
- HABIT TRAINING IS USED FOR PATIENTS THAT ARE FOR INSTANCE HAVING DEMENTIA OR THEY ARE CONFUSED
AND CANNOT REALLY RECOGNIZE THE URGE TO VOID, ALTHOUGH THE PHYSIOLOGIC IS INTACT. YOU CAN DO
HABIT TRAINING, WHERE YOU JUST TAKE THEM TO THE BATHROOM ON A SCHEDULE.
- MANAGING INCONTINENCE
O HAVE ABSORBENT PADS
O KEEP THE CLIENT DRY
O MAINTAIN SKIN INTEGRITY

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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.

DEFECATION IS ALSO CONTROLLED IN THE SACRAL SEGMENT OF THE CORD.


IF YOU HAVE AN UPPER MOTOR NEURON
T12. IF YOU HAVE A LOWER MOTOR NEURON LESION IT IS T12 AND BELOW. WITH A LOWER
LESION IT IS ABOVE
MOTOR NEURON LESION, YOU LOSE YOUR REFLEX ARC, THEN YOU HAVE NO TONE OF THE BLADDER AND VERY LITTLE
BOWEL FUNCTION. CAN HAVE BOWEL DYSFUNCTION DUE TO INJURY (SPINAL CORD) OR COGNITIVE FACTORS, IMMOBILITY
AND MOST COMMONLY WITH THE NEURO PATIENT CONSTIPATION IS GOING TO BE THE PROBLEM.

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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- DIETARY – INCREASED FLUID (WATER) AND BULK (FIBER)


- INCREASE ACTIVITY AND EXERCISE – HELPS WITH GI MOTILITY
- PROVIDE PRIVACY
- IF IT IS POSSIBLE TO GET THESE PATIENTS IN AN UPRIGHT POSITION, IT MAKES IT MUCH EASIER FOR THIS CLIENT
TO GO TO THE BATHROOM.
- MEDICATIONS THAT WE MIGHT USE – BULK FORMERS (METAMUCIL, FIBERCON), STOOL SOFTENERS (COLACE),
LAXATIVES (MOM, EXLAX), AND GLYCERIN SUPPOSITORIES (DUCOLAX)
- ENEMAS MIGHT BE NECESSARY, BUT THEY CAN BE CONTRAINDICATED WITH SOME PATIENTS PARTICULARLY
PATIENTS WITH INCREASED INTRACRANIAL PRESSURE (ICP).

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 SYSTEM COMPLEX – MOTOR IMPULSE TRAVERSES 2 NEURONS AT LEAST

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

UPPER MOTOR NEURON – (UMN)


- MOTOR NEURONS LOCATED IN THE CEREBRAL CORTEX., THE CEREBELLUM, AND THE BRAIN STEM. UPPER
MOTOR NEURONS ARE CONTAINED COMPLETELY WITHIN THE CENTRAL NERVOUS SYSTEM (THE BRAIN AND THE
SPINAL CORD).
- MODULATE OR REGULATE THE ACTIVITY OF THE LOWER MOTOR NEURONS
- HAVE A NERVE IMPULSE THAT STARTS IN THE BRAIN TRAVELS TO THE SPINAL CORD, THEN GOES DOWN TO THE
LOWER MOTOR NEURONS THAT ARE IN THE CORD AND EXIT THE CORD AND GO INTO THAT SKELETAL MUSCLE.
SO WHEN YOU MAKE A CONSCIOUS DECISION TO MOVE YOUR HAND, THAT STARTS IN YOUR BRAIN, IT TRAVELS
THROUGH THIS UPPER MOTOR NEURON SYSTEM AND IT GOES TO THE LOWER MOTOR NEURON SYSTEM, WHICH
ACTUALLY REACHES THE SKELETAL MUSCLE AND YOUR HAND MOVES. THIS IS AN UPPER MOTOR NEURON
FUNCTION.

LOWER MOTOR NEURON – (LMN)


- LOCATED IN THE SPINAL CORD GRAY MATTER IN THAT ANTERIOR HORN OF SPINAL CORD FIBER, CRANIAL NERVE
IN THE BRAIN STEM, THE AXONS EXTEND THROUGH PERIPHERAL NERVES. AXONS SEND IMPULSES AWAY FROM
THE CNS (BRAIN). THE PERIPHERAL NERVES INERVATE THE SKELETAL MUSCLES AND ACTUALLY TELL THE
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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.

UPPER MOTOR NEURON LESIONS


- GOING TO INVOLVE ANYTHING ABOVE THE T12 VERTEBRAL LEVEL OF THE SPINAL COLUMN IS CONSIDERED UPPER
MOTOR NEURON LESIONS.
- LOSS OF VOLUNTARY CONTROL. THESE ARE THE THINGS THAT YOU CAN CONTROL ON PURPOSE IN THE
CEREBRAL HEMISPHERE. A LOT OF THE UPPER MOTOR NEURON IS PURPOSEFUL.
- ↑ MUSCLE TONE – BECAUSE YOU HAVE THE LOWER MOTOR NEURON REFLEX ARC INTACT, BUT YOU DON’T HAVE
THE UPPER MOTOR NEURON ABILTY TO MEDIATE THAT RESPONSE. SO WHEN YOU LOSE UPPER NEURON
FUNCTION, YOU LOSE THE ABILITY TO MODULATE/REGULATE YOUR LOWER MOTOR NEURON REFLEXES.
- MUSCLE SPASTICITY
- LITTLE OR NO MUSCLE ATROPHY
- HYPERACTIVE AND ABNORMAL REFLEXES
- THIS IS WHY WHEN YOU HAVE A CLIENT THAT HAS A STROKE AND THEY HAVE HEMIPARESIS OR HEMIPARESIA ON
ONE SIDE THEY ARE HYPER-REFLEXIVE. THEY HAVE AN UPPER MOTOR NEURON LESION. THEY HAVE LOST THEIR
VOLUNTARY CONTROL, BUT WHEN YOU CHECK THEIR DEEP TENDON REFLEXES, THEY ARE HYPEREFLEXIVE ON
THAT SIDE BECAUSE YOU HAVE THAT LOWER MOTOR NEURON REFLEX ARC INTACT.

LOWER MOTOR NEURON LESIONS


- WILL INVOLVE ANYTHING AT OR BELOW T12 VERTEBRAL LEVEL
- LOSS OF VOLUNTARY CONTROL
O IF YOU HAVE AN INJURY TO THE PERIPHERAL NERVES BETWEEN YOUR SPINAL CORD AND THIS
PARTICULAR SKELETAL MUSCLE, YOU LOSE THE REFLEX ARC (BECAUSE THE NERVE IS SEVERED), YOU
ALSO LOSE THE ABILITY TO GET THE IMPULSE FROM YOUR BRAIN TO THAT MUSCLE AS WELL. THIS IS
BECAUSE THERE HAS BEEN AN INTERUPTION IN THAT NERVE IMPULSE.
- ↓ MUSCLE TONE (BECAUSE REFLEX ARC IS LOST)
- FLACCID PARALYSIS OF MUSCLES – MIGHT HAVE FLACCID PARESIS DEPENDING ON THE EXTENT OF THE INJURY
(THIS IS BECAUSE THEY HAVE LOST THAT REFLEX).
- MUSCLE ATROPHY (AS AN ADULT, YOU WILL HAVE MUSCLE ATROPHY)
- ABSENT OR VERY DIMINISHED REFLEXES (DEPENDING UPON THE EXTENT OF THE INJURY OF THE LOWER MOTOR
NEURON)

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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- INFANT – NERVOUS SYSTEM DEVELOPS WITHIN 1 ST


YEAR,

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,

DIFFERENT TYPES OF APHASIA


- EXPRESSIVE APHASIA – DIFFICULTY EXPRESSING AND COMMUNICATING THEIR THOUGHTS
- RECEPTIVE APHASIA – DIFFICULTY UNDERSTANDING OR RECEIVING THE MESSAGE
- GLOBAL/MIXED APHASIA – SOME RECEPTIVE AND EXPRESSIVE APHASIA GOING ON

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)

IF THE CLIENT CANNOT FOLLOW INSTRUCTIONS – THIS MAY BE A RECEPTIVE PROBLEM.

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.

FACTORS THAT MAY AFFECT ASSESSMENT


- ALTERED LOC
- DYSARTHRIA – IMPAIRMENT OF SPEAKING DUE TO DISEASE IN THE MUSCLE USED FOR SPEECH – THIS IS GOING
TO AFFECT YOUR ASSESSMENT OF THEIR ABILITY TO COMMUNICATE. THEY CANNOT SPEAK BECAUSE OF THE
PARALYZED MUSCLES, BUT THEY WILL BE ABLE TO WRITE YOU A BOOK ABOUT WHAT THEY WANT OR NEED.
- VISUAL FIELD CUTS
- LOWERED VISUAL ACUITY
- HEARING LOSS
- COGNITIVE DEFICITS
- MEMORY DEFICITS
- LANGUAGE BARRIERS

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

INTERVENTIONS (PAGE 1900 – BRUNNER)


- MAINTAIN EYE CONTACT, YOU WANT TO MAKE SURE THAT THEY CAN SEE YOUR MOUTH MOVING AS WELL.
- DECREASE BACKGROUND NOISE
- CALM, REASSURING, SUPPORTIVE MANNERS
- SPENDING TIME AND AN UNHURRIED APPROACH
- SPEAK VERY CLEARLY – USE SHORT PHRASES – IF THEY ARE HAVING RECEPTIVE PROBLEMS, YOU WANT TO GIVE
THEM SIMPLE, SHORT COMMANDS. DO NOT WANT TO GIVE THEM A WHOLE LOT TO PROCESS.
- USE GESTURES
- USE OBJECTS
- USE TACTILE STIMULI – HUG, HAND PAT, SMILE (FOR ENCOURAGEMENT)
- “SLATE BOARD” – USED TO COMMUNICATE THROUGH WRITING (EXPRESSIVE APHASIA, DYSARTHRIA)
- PICTURE/WORD/PHASE BOARD – THEY CAN POINT TO WHAT THEY NEED
8
TCA 2

SEIZURES – BRIEF CEREBRAL STORM


- EPISODES OF ABNORMAL MOTOR, SENSORY, AUTONOMIC, OR PSYCHIC ACTIVITY AS A CONSEQUENCE OF SUDDEN
EXCESSIVE DISCHARGE FROM CEREBRAL NEURONS (SUDDEN CEREBRAL STORM OF ELECTRICAL ACTIVITY IN THE
BRAIN)
O A SEIZURE IS A SYMPTOM OF AN UNDERLYING CONDITION.
ONE OF THE COMMON PROBLEMS THAT CAN
RESULT FROM ALL DIFFERENT TYPES OF PROBLEMS IN THE BRAIN.
O CAN EFFECT/INVOLVE ALL OR PART OF THE BRAIN
O USUALLY SUDDEN AND TRANSIENT (COME QUICKLY AND GO QUICKLY)
O MEMORY LOSS IS VERY COMMON DURING AND SHORTLY AFTER A SEIZURE. THEY USUALLY HAVE NO
MEMORY OF THE SEIZURE ITSELF. THEY WILL WAKE UP AND SAY WHAT HAPPENED?

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.

THIS ELECTRICAL DISTURBANCE CAN CAUSE:


• A LOSS OF CONSCIOUSNESS.
• EXCESSIVE MOVEMENT OR LOSS OF MUSCLE TONE
• LOSS OF MOVEMENT
• A DISTURBANCE IN BEHAVIOR
• A DISTURBANCE IN MOOD
• A DISTURBANCE IN SENSATION OR PERCEPTION
• ALL OF THIS DEPENDS ON WHAT AREA OF THE BRAIN IS 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

EPILEPSY CAN BE:


• IDIOPATHIC/PRIMARY
• SECONDARY

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.

SOME CAUSES OF EPILEPSY (ANY OF THESE CAN LEAD TO EPILEPSY)


• HEAD TRAUMA
• CNS INFECTIONS (MENNINGITIS)
• CEREBRAL TUMOR
• CEREBRAL VASCULAR DISEASE
• STROKE

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TCA 2

• BIRTH INJURIES (WHERE MAYBE THEY LOST OXYGENATION AT BIRTH)


• TOXINS
• GENETIC DEFECTS

CAUSES CAN BE:


• IDIOPATHIC – GENETIC, DEVELOPMENTAL DEFECTS
• ACQUIRED
O HYPOXEMIA (LACK OF O2 TO THE BRAIN TISSUES, MIGHT HAVE BEEN DUE TO A STROKE, MIGHT HAVE BEEN
DUE TO A NEAR DROWING),
O VASCULAR INSUFFICIENCY (NOT ENOUGH BLOOD GETTING TO THE BRAIN)
O FEVER IN CHILDREN (CALLED FEBRILE SEIZURES)
O HEAD INJURY
O HTN
O CNS INFECTIONS
O METABOLIC AND TOXIC CONDITIONS
O DRUG AND ALCOHOL WITHDRAWELS
O POSSIBLY ALLERGIES
O RENAL FAILURE
O CONDITIONS FROM DIABETES
O BRAIN TUMORS
O CEREBROVASCULAR DISEASE IS BY FAR THE MOST COMMON CAUSE OF SEIZURES IN THE ELDERLY.

TWO WAYS THAT SEIZURES CAN BE CLASSIFIED: (CHART ON PAGE 1874)


1. PARTIAL SEIZURES
• PARTIAL SEIZURES MEANS THAT THE SEIZURE BEGINS LOCALLY. THERE IS A SPECIFIC AREA OF
THE BRAIN WHERE THAT SEIZURE BEGAN.
• CAN BE FURTHER DIVIDED INTO:
O SIMPLE PARTIAL SEIZURES

 VERY ELEMENTARY SYMPTOMS


 THEY CAN BE MOTOR OR SENSORY.
 USUALLY THESE CLIENTS DO NOT LOSE CONSCIOUSNESS
O COMPLEX PARTIAL SEIZURES

 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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TCA 2

PHASES OF THE GENERALIZED SEIZURE:


• TONIC CLONIC SEIZURE – TEXTBOOK SEIZURE, WHAT MOST PEOPLE THINK ABOUT WHEN THEY THINK OF A
GENERALIZED GRAND MAL SEIZURE.
O TONIC PHASE – THIS IS THE PHASE THAT BEGINS THE SEIZURE. YOU ARE GOING TO

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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TCA 2

 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

NURSING CARE DURING A SEIZURE (PAGE 1875)


- ABOVE ALL, WE WANT TO PREVENT INJURY TO THIS CLIENT. THIS INCLUDES AIRWAY. AIRWAY OF COURSE IS
PRIORITY.
- PROVIDE PRIVACY AND PROTECT THE PATIENT FROM CURIOUS ON-LOOKERS (THEY MIGHT BE INCONTINENT)
- EASE THE PATIENT DOWN TO THE FLOOR; IF POSSIBLE
- PROTECT THE HEAD WITH A PAD TO PREVENT INJURY
- LOOSEN CONSTRICTIVE CLOTHING, ESPECIALLY AROUND THE NECK
- PUSH ASIDE ANY FURNITURE THAT MAY INJURE THE PATIENT DURING THE SEIZURE

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TCA 2

- 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 CARE AFTER THE SEIZURE


- KEEP THE PATIENT ON ONE SIDE TO PREVENT ASPIRATION. MAKE SURE THE AIRWAY IS PATENT
- THERE IS USUALLY A PERIOD OF CONFUSION AFTER A GRAND MAL SEIZURE. (EXPECT THIS) REORIENT THE
CLIENT IF NECESSARY.
- A SHORT APNEIC PERIOD MAY OCCUR DURING OR IMMEDIATELY AFTER A GENERALIED SEIZURE. IF THE CLIENT
DOES NOT START TO BREATHE AGAIN ON THEIR OWN, NEED TO START CPR.
- THE PATIENT, ON AWAKENING, SHOULD BE REORIENTED TO THE ENVIROMENT
- IF THE PATIENT BECOMES AGITATED AFTER A SEIZURE, USE CALM PERSUASION AND GENTLE RESTRAINT. CALM
AND REASSURE THE CLIENT.

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

SIDE EFFECTS OF ANTICONVULSANT MEDICATIONS IN GENERAL:


- DROWSINESS– VERY COMMON ESPECIALLY WHEN BEGINNING ANTI-SEIZURE THERAPY
- LETHARGY – VERY COMMON ESPECIALLY WHEN BEGINNING ANTI-SEIZURE THERAPY
- HAVE THE CLIENT KEEP A DRUG DIARY THAT INCLUDES THE CURRENT DOSAGE THAT THEY ARE ON, THE SIDE
EFFECTS THAT THEY ARE EXPERIENCING. ALSO NEED TO KEEP A DIARY OF THEIR SEIZURE ACTIVITIES WHILE
THEY ARE ON THESE MEDICATIONS.
- SOME HAVE SIDE EFFECTS OF BLOOD DYPLASIAS OR ANEMIA. SO IN THIS CASE, CLIENT NEEDS TO BE
MONITORED FREQUENTLY AND HAVE CBC’S DRAWN.
- SERUM DRUG LEVELS SHOULD BE DRAWN PERIODICALLY
- FOLIC ACID AND VITAMIN D DEFICIENCY HAS BEEN SEEN IN CLIENTS ON LONG TERM ANTI-CONVULSANT
THERAPY. SO WE MIGHT NEED TO OFFER A SUPPLEMENT.

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.

COMMON MEDICATION TOXICITY LEVELS:


- TEGRETOL 4 – 12 IS THE THERAPEUTIC LEVEL
- PHENOBARB 10 – 40 IS THE THERAPEUTIC LEVEL.
- DILANTIN/CEREBYX 10 – 20 IS THE THERAPEUTIC LEVEL – IT DOES NOT TEND TO HAVE THE SEDATIVE
EFFECTS THAT SOME OF THE OTHERS DO. ONE OF THE MAJOR SIDE EFFECTS OF DILANTIN IS GINGIVAL
HYPERPLASIA. SO WE NEED TO TEACH OUR CLIENTS TO DO FREQUENT AND METICULOUS ORAL CARE. ALSO
ASSESS THE CLIENT ON DILANTIN FOR A RASH (MAY BE FROM HEAD TO TOE). IT MAY BE SO BAD THAT THEY
HAVE TO DISCONTINUE THIS MEDICATION AND THE CLIENT WILL HAVE TO BE PUT ON CORTICOSTEROIDS TO
ALLEVIATE THE RASH AND ANOTHER ANTICONVULSANT WILL HAVE TO BE TRIED. IF GIVING DILANTIN VIA IV, IT IS
COMPATIBLE WITH ONLY NORMAL SALINE. IF IVPUSH, CAN ONLY GIVE IT AT 50MG/MINUTE, NEEDS TO
GIVING IT
BE PUSHED VERY SLOWLY (VERY IRRITATING TO THE VEINS).
- DEPAKOTE 50 – 100 IS THER THERAPEUTIC LEVEL. DEPAKOTE IS ALSO USED FOR MOOD DISORDERS
- NERONTIN IS AN ANTICONVULSANT THAT IS ALSO USED FOR PAIN (ESPECIALLY NEUROGENIC PAIN)
- TOPAMAX
- CARBITROL

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.

SEIZURE MANAGEMENT IN THE COMMUNITY SETTING


- TEACH CLIENT AND TEACH FAMILY MEMBERS SAFETY INTERVENTIONS (LISTED ABOVE)
- SIGNS THAT YOU NEED TO CALL 911 FOR:
• IF THE CLIENT STOPS BREATHING AFTER A SEIZURE (AND NEED TO START CPR)
• IF THEY HAVE A GENERALIZE CLONIC-TONIC SEIZURE THAT IS LASTING FOR MORE THAN 2
MINUTES.
• IF THE PERSON START TO HAVE ONE SEIZURE AFTER ANOTHER.
• IF THE PERSON IS INJURED
• OTHERWISE, TRY AND WAIT FOR THE SEIZURE TO SUBSIDE. MONITOR THE CLIENT.

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

MAJOR NURSING DIAGNOSIS FOR THE CLIENT WITH SEIZURES:


- R/F INJURY

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TCA 2

17
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
20
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

COMPARISON OF POSTOPERATIVE CARE


SUPRA TENTORIAL INFRATENTORIAL
• INCISION DIRECTLY OVER THE AREA TO BE • INCISION MADE SLIGHTLY ABOVE THE NAPE OF THE
EXPLORED ON CEREBRAL CORTEX. NECK AROUND THE OCCIPITAL REGION

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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

• AMBULATION – OUT OF BED ON 2 ND


TO 5 TH
• AMBULATION – OUT OF BED 6 – 10
TH TH
DAY POST-
DAY POST-OP OP. PATIENT WILL EXPERIENCE DIZZINESS
• NUTRITION – NPO FOR 24 HOURS: IV • NUTRITION – NPO AT LEAST 24 HOURS. WATCH
FLUIDS. WATCH FOR ORDERS FOR FLUID FOR FLUID RESTRICITON MUST CHECK GAG AND SWALLOW
RESTRICTIONS REFLEX

• 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

DRUGS USED ARE CORTICOSTEROIDS, ANALGESICS, ANTIMICROBIAL AGENTS


(CONTINUED UNTIL NASAL PACKING IS
REMOVED), AND AGENTS FOR CONTROL OF DIABETES INSIPIDUS WHEN NECESSARY.

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