Headaches

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Headaches
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Dx

• History and Physical
• Neurologic exam
• Lab studies CBC, electrolytes, urinalysis
• CT scan of sinuses
• CT scan, angiography, EMG, EEG, MRI

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Tension Headache

• Common type of headache
• No prodrome
• Bilateral, bandlike pressure at the base of
  skull, face, or in both
• Constant, squeezing tightness
• Intermittent for months or years
• Not related to time
• Associated symptoms palpable neck and shoulder
  muscles, stiff neck tenderness

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Treatment

• ASA, Tylenol, Ibuprfen, muscle relaxant,
  antidepressant, tranquilizer codeine
• Biofeedback
• Meditation, Yoga
• Acupuncture, Acupressure, Message
• Hypnosis
• Psychotherapy
• Relaxation techniques

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Migraine

• Family hx of migraine can be found in 65 of
  patients
• HA may be preceded with prodrome and aura
• Migraine with aura
• Migraine without aura
• Factors that precipitate HA fatigue
• stress, menstration, chocolate, coffee, alcohol

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Migraine

• Unilateral, may switch sides
• Throbbing
• Continuous for hours or days
• Onset after awakening gets better with sleep
• Associated symptoms N/V, irritability, sweating,
  photophobia, prodrome of sensory or motor,
  psychic disturbances, GI upset, changes in fluid
  disturbances

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Treatment

• ASA, Tylenol, Ibuprofen, narcotics
• Ergotamine allows more epinephrine to constrict
  vessels
• Sumatriptan serotonin receptor agonist
• Beta blockers
• Calcium channel blockers
• Antidepressants
• Biofeedback, relaxation techniques, behavioral
  therapy
• Dark quiet room, lay down, ice packs, reduce
  stimuli

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Cluster

• Unilateral, radiating up or down from one eye
• Severe, bone crushing
• 30-90 minutes
• Noctural, commonly awakens pt. from sleep
• Associated symptoms facial flushing, or pallor,
  unilateral lacrimation, ptosis, rhinitis

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Treatment

• Ergotamine
• NSAIDs
• Beta blockers
• O2
• Sumatriptan
• Narcotics
• Biofeedback

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Nursing Assessment of HAs

• Location and type of pain, onset, frequency,
  duration, relations to events (emotional,
  psychologic, physical), time of day of occurrence
• Information about previous illness, surgery,
  trauma, allergies, family hx, medications

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Teaching Guide

• Teach pt to keep a dairy of HA episodes and
  precipitating events
• Avoid factors that may trigger a HA chocolate,
  coffee, fatigue, emotional stress, red wines
• Describe purpose, action, dosage, and side
  effects of drugs taken
• Instruct on relaxation techniques, regular
  exercise
• Contact MD if symptoms become more severe,
  resistant to medications, N/V, change in vision,
  fever with HAs, problems with drugs

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Nursing DX
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Seizure Disorders

• A paroxysmal, uncontrolled electrical discharges
  of neurons in the brain that interrupt normal
  function
• May be due to cerebral hypoxia, head injury,
  acidosis, hypoglycemia, alcohol, water
  intoxication
• Epilepsy a condition characterized by recurrent
  seizures

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Seizures

• Classification of seizures generalized and
  partial
• A seizure may progress through phases
• Prodromal phase with signs or activity which
  precede a seizure
• Aural phase sensory warning
• Ictal phase full seizures
• Postictal phase recovery after a seizure

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Generalized Seizures

• Tonic-clonic seizure or grand mal
• Sudden loss of consciousness
• Tonic phase 10-20 seconds, entire body
  stiffens, jaws fixed and hands clenched
• Clonic phase 30-40 seconds, jerking of
  extremities, cyanosis, excessive salivation,
  incontinent of stool or urine
• Entire episode may last for 2 minutes and pt may
  be sleepy, fatigue, experience muscle soreness,
  has no memory of episode and may not feel normal
  for several hours or days

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Absence Seizures

• Petit mal seizures
• Occurs in children may disappear after puberty or
  evolve into another type of seizure
• Brief periods of altered consciousness staring,
  blinking eyes 10-15 sec
• Misdiagnosed as lack of attention or not
  diagnosed

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Myoclonic seizure

• Sudden excessive jerking of body and extremities,
  period of unconsciousness, less than 5 sec
• Drop attacks or Falling spells tonic episode,
  consciousness occurs by time the pt hits the
  ground
• Akinetic arrest of movement
• Atonic loss of tone
• Astatic loss of balance

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Partial Seizures

• Seizures begin in a specific region of the cortex
• May be confined to one side of the brain and may
  spread to involve the entire brain developing
  into a generalized tonic-clonic seizure
• Partial seizures simple partial and complex
  partial seizures

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Simple Partial Seizure

• Motor doesnt effect loss of consciousness,
  begin with convulsive twitching in upper
  extremity and may spread to entire limb
• Sensory doesnt effect loss of consciousness,
  experiencing sensory phenomena, pt sees flashing
  lights or experiences numbness and tingling

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Complex Partial Seizures

• Location of seizure activity temporal lobe
• Seizures last longer than 1 minute and followed
  by a period of postictal confusion
• Most common psychomotor seizures involves
  repetitive movement such as patting of body,
  picking at clothes, smacking at the lips
• Variety of psychomotor symptoms may occur such as
  distortion of visual and auditory sensation and
  vertigo
• Alteration in memory, thought process, sexual
  functioning

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Status Epilepticus

• A state of continuous seizure activity or
  seizures in rapid succession without the return
  to consciousness between seizures
• Medical emergency
• May result in brain damage

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Diagnostic

• History and Physical developmental history,
  illnesses and injuries, febrile seizures,
  comprehensive neurologic assessment
• Seizure history precipitating factors, seizure
  description
• Lab studies, lumbar puncture, CT, MRI, EEG

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Treatment Medications

• Antiseizure medications 70 controlled by
  medications
• Drug therapy begins with a single dose and
  increase dosage until seizures are controlled or
  toxic effects (diplopia, drowsiness, hand and
  gait coordination) occur check lab, must be
  given on time
• Drugs Dilantin, Tegretol, Phenobarbital
• New drugs available with long half life

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Medications

• Dilantin, Tegretol Phenobarbital treat
  tonic/clonic partial seizures
• Dilantin causes gingival hyperplasia good
  dental hygiene
• Zarontin, Depakote, Klonopin treat myclonic
  seizures

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Surgery other therapies

• Removal of epileptic focus in the brain
• Vagal nerve stimulator device delivers
  intermittent electrical stimulation to the brain
  to reduce frequency and intensity of seizures
• Biofeedback

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Nursing Care of Seizure Pt

• Observe and record details of event
• Note all aspects of the seizure
• What event preceded the seizures?
• When did the seizure occur?
• How long did each phase last?
• What occurred during each phase?

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During the Seizure Activity

• Maintain airway stay with pt.
• Turn pt to the side
• Protect the head
• Loosen clothing
• Ease pt to the floor
• Do not restrain pt
• No objects should be placed into the mouth
• After seizure may need suctioning and O2

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Teaching Guide

• Drugs taken as prescribed
• Follow up with lab work
• Instruct on relaxation techniques, biofeedback
• Community resources
• ID bracelet emotional support
• Avoid excessive alcohol, fatigue, loss of sleep
• Regular meals snacks
• Family member instruction care during a
  seizure, swim and horse back with friend, take
  shower instead of bath, driving

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Meningitis

• An acute inflammation of the pia mater and the
  arachnoid membrane surrounding the brain and
  spinal cord
• Organism gains entry by the CNS through upper
  respiratory tract or the bloodstream, direct
  extension from penetrating wound of the skull
• Increase CSF production, ICP, purulent secretion
  produced quickly spreads to other areas of the
  brain

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Common Organisms

• Bacterial Meningitis - Streptococcus pneumoniae
  and Neisseria meningitidis
• Haemophilus influenzae was a common cause, a
  vaccine used to decrease this
• Bacterial Meningitis - high mortality, high
  morbidity, medical emergency

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Clinical Manifestations

• HA becomes progressively worse
• Chills
• Fever
• N/V
• Nuchal rigidity
• Photophobia
• Generalized seizures

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Clinical Manifestations

• Decreased LOC
• IICP
• Brudzinskis sign forward neck flexion with the
  pt supine, produces flexion of both thighs at the
  hips and flexion movements of the ankles and
  knees
• Kernigs sign pain, hamstring muscle spasm and
  resistance to further leg extension at the knees
  when the thigh is flexed at a right angle to the
  abdomen, the knee is flexed 90 degree to the
  thighs and then the lower leg is extended

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Common Complications

• Cranial nerves III, IV, VI, VII, VIII
• Hearing loss may be permanent after bacterial
  meningitis and usually disappears with in a few
  weeks, not a complications of viral meningitis

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DX Studies

• History and physical
• Analysis of CSF, lab work, blood culture
• CT scan, MRI, PET
• Skull x-rays

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Medical Management

• Medical emergency
• IV antibiotics (PCN), IV fluids
• Analgesia for HA
• Tylenol
• Dilantin
• Lasix or mannitol
• Bedrest

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Viral Meningitis

• Common causes enteroviruses, arboviruses, HIV,
  herpes simplex
• S/S HA, drowsiness, photophobia, weakness, rash,
  temperature
• Assess signs of meningitis

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CSF

• Protein levels in CSF increase in bacterial
  than in viral
• Decrease CSF glucose in bacterial meningitis and
  normal glucose in viral
• CSF - purulent and cloudy in bacterial and may be
  clear in viral meningitis

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Nursing Care