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