Altered Intracranial Functioning

Care of the Client with Altered Intracranial

Functioning

HeadachesSeizures

Meningitis/Encephalitis

Objectives

• Define the basic pathophysiology behind headaches, seizures, meningitis and encephalitis, and cranial nerve disorders

• Describe expected assessment findings for these conditions

• Develop a collaborative plan of care including nursing and medical orders

Seizure DisordersA seizure is a sudden discharge of

uncontrolled electrical activity in the brain Common causes:

• Idiopathic: genetic, developmental• Acquired: head trauma, stroke, alcohol/drug

withdrawal, hypoglycemia, hyponatremia…….

Epilepsy: recurrent, unprovoked seizure activity

Types of Seizures: Generalized

Tonic-Clonic(Grand Mal)

Stiffening of muscles, followed by rhythmic jerking of all extremities; lasts 1-3 min.

Absence(Petit Mal)

Brief periods of staring with loss of awareness

Myoclonic Paroxysmal jerking of a muscle group

Atonic(Akinetic)

Sudden loss of all muscle tone

Types of Seizures:Partial

Simple Movement of extremity or unusual sensation;No loss of awareness

Complex(Temporal lobe or Psychomotor seizure)

Repetitive movements(“automatisms”) or emotional outbursts;Loss of awareness

Seizure DisordersPhases of a seizure

• Pre-ictal —aura• Ictal—seizure• Post-ictal—recovery after seizure

Diagnostics• EEG• CT or MRI• Labs to r/o metabolic cause

Seizure Disorders:Nursing Care

High Risk for Injury; High Risk for Ineffective Breathing Pattern

• Seizure precautions•Maintain a med lock for medication

access•Assure suction, oxygen are available•Padded bed rails may be used

Seizure Disorders:Collaborative Care

Acute Seizure Management• Prevent injury from falls; remove nearby objects. Do

NOT restrain• Provide oxygen and suction as possible; do not force

anything into mouth• Administer rapid-acting medication, such as a

benzodiazapine (e.g. Ativan); follow with Dilantin or other drug with longer action time

Status Epilepticus—seizure activity lasting more than 30 minutes; a neurological emergency

Seizure Disorders: Collaborative Care

Post Seizure Management (con’t)

*Protect the airway• administer oxygen and stimulate to breathe as needed• suction as needed• position on side *Monitor until LOC returns*Reorient as needed*Document the event

Seizure Disorders:Collaborative CareMedications are the mainstay of Treatment

Client Education:• Take meds as ordered; do not stop suddenly• Keep lab appointments• Good dental hygiene• Diet precautions• Medic alert bracelet• Safety precautions• Contraceptive precautions• Depression signs/symptoms

Seizure Disorders:Collaborative CareOther anti-epileptic interventions

• Vagal nerve stimulation—disrupts synchronization of epileptic impulse

• Surgery• Temporal lobectomy for uncontrolled complex

partial seizures• Corpus collosum transection for uncontrolled

seizures from unknown focus

Headaches

• A symptom, not a disease• Caused by inappropriate

vasodilation of cerebral vessels• Types

• Primary: no organic cause identified; e.g. migraines

• Secondary: associated cause; e.d. brain tumor

Primary Headaches:Migraine • A unilateral throbbing in the frontal

or temporal areas• Associated symptoms may include

nausea & vomiting, and/or photophobia/phonophobia

• Phases• Prodrome/aura• Headache• Recovery

Primary Headaches:Migraine

Nursing Interventions• Assist client to identify triggers

• Common triggers include foods, odors, stress

• Encourage headache log

• Administer medications• Management of acute pain:

• Triptan drugs (eg Imitrex, Relpax)• NSAIDs• Anti-emetics as needed

Primary Headaches:Migraine

Medications (con’t)

•Preventive Therapy• Beta blockers (e.g. Inderal)• TCAs (e.g. Elavil)• Anti-seizure medicines (e.g. Topamax)

Other interventions• Rest in a dark, quiet environ• Relaxation/Biofeedback• Herbals: Feverfew, Butterbur

Primary Headaches:Cluster Headaches

• Unilateral intense, boring, pain around the eye which may radiate to temple, cheek, or back of head

• Associated sx of ipsilateral tearing, ptosis, rhinorrhea, and/or facial flushing

• Client may pace or rock

Primary Headaches: Cluster Headaches

Treatment• Medications as for migraines: triptans, Topamax• Oxygen 100% for 15 minutes• Sunglasses for ptosis/eye pain• Avoid potential triggers: alcohol,

stress, toxin exposure

Primary Headaches:Cranial (Temporal) Arteritis• Inflammation of cranial arteries in

temporal region• Characterized by fever, redness,

warmth over affected artery; possibly visual deficits

• Treated with steroids and pain medications

Meningitis• An inflammation of the meninges of the brain and spinal cord

• Organism crosses the blood-brain barrier as a result of sinusitis, otitis, or trauma

• Types of meningitis• Bacterial—most serious

• Strep or Neisseria most common organisms

• Viral (aseptic)• Fungal—most common in immune

suppressed individuals

MeningitisClient Appearance• Infectious signs

• Fever, chills, tachycardia• Petechial rash & purpura in Neisseria

• Meningeal signs• Photophobia• Headache• Nuchal rigidity

• Neurologic signs• Change in orientation or LOC• Change in behavior• Seizure activity

MeningitisDiagnosis is confirmedby lumbar puncturewith analysis of CSF• Obtain client signature of

informed consent• Assist into fetal position

Post Procedure Care:• Bedrest 2-8 hours• Monitor site• Force fluids• Medicate for headache

Assessing drainage for CSF

• Halo sign

• + for glucose

Meningitis: Nursing Care

Ineffective Cerebral Tissue Perfusion d/t Infection

• Droplet precautions until infective organism known

• Administer antibiotics ASAP!• Monitor neuro status frequently to

detect changes in mental status• Monitor for seizure activity• Monitor for complications of disease, inc.

hearing, visual, and cognitive impairment

Meningitis:Nursing Care• Frequent neurological checks

Meningitis: Nursing Care

Pain• Non-opiod for headache relief• Decadron to reduce inflammation• HOB elevated• Reduce environmental stimuli

Other Nursing Care issues• Monitor for complications of decreased

tissue perfusion • Encourage vaccination!

Encephalitis

• An acute inflammation of the brain resulting in brain edema and areas of

necrosis• Infective agent usually viral, most

commonly from mosquito or tick bite

Encephalitis

Client Appearance• Fever• Headache• Change in mental status• Motor deficits, inc. tremors, ataxia,

hemiparesis, myoclonic jerks or other seizures

• Meningeal signs

Encephalitis

Diagnostics:• Blood work to identify infective organism• MRI or PET scan• LP

Collaborative Care• Administer anti-infectives if bacterial or fungal

source suspected• Monitor neurologic status• Supportive care to prevent complications

Trigeminal Neuralgia (Tic Douloureux)• A disorder of CN 5 which

results in a unilateral stabbing facial pain

• Pain comes in bursts• May have twitching of eye

or mouth on affected side• May have sensory loss on

affected side• No accompanying motor

deficits

Trigeminal Neuralgia Nursing Assessment• Triggering factors • Hygiene and nutritional status

Collaborative Care• Pain management (medical)

• Neuro inhibitors, such as Tegretol, Neurontin• Biofeedback

• Invasive interventions • nerve blocks • surgical relief of pressure on nerve• radiofrequency ablation of the nerve• balloon micro-compression of nerve

Facial Paralysis (Bell’s Palsy)

• Inflammation of CN VII results in unilateral paralysis of facial muscles on affected side; may be associated loss of taste &/or hearing, or increased tearing.

• Pain behind the ear or on the face may precede the onset

• No diagnostic tests

Facial Paralysis (Bell’s Palsy)Nursing Care• Pain management: anti-

inflammatories, steroids • Eye care to prevent drying or injury• Monitor for aspiration of food/ fluids; diet education of client• Monitor intake to assure adequate

nutrition• Facial exercises