MNCHN Finals Coverage this by altering the cerebral perfusion pressure via

vasoconstriction or vasodilation. For example, if carbon

NEUROLOGIC DISORDERS dioxide levels are abnormally high (>45) vasodilation
occurs, which allows more blood volume to enter the
INCREASED INTRACRAINIAL PRESSURE brain. However, this is not good if a patient has
What is increased intracranial pressure? It’s where increased ICP because this will further increase the ICP.
pressure inside the skull has increased. This is a medical • Cerebral perfusion pressure can become
emergency! compromised during increased intracranial
• Intracranial pressure is the pressure created by pressure. Therefore, there must be a sufficient
the cerebrospinal fluid and brain tissue/blood cerebral perfusion pressure so that the brain is
within the skull. It can be measured in the lateral properly maintain.
ventricles.
• What is a normal ICP (adults): 5-15 mmHg (>20
mmHg…needs treatment)
• ICP in children normally ranges from 1 to 10
mmHg; a level greater than 15 mmHg needs
further assessment.
Pathophysiology of Increased Intracranial Pressure
The skull is very hard and is limited on how much it can
expand when something inside the skull experiences a
change that leads to increased pressure.
Inside the skull are three structures that can alter
intracranial pressure:
• brain
• cerebrospinal fluid (CSF)
• blood

What can cause an increased pressure within the skull

that leads to increased intracranial pressure?
• injury (head trauma)
• increased in cerebrospinal fluid
• hemorrhage (hemorrhagic stroke…aneurysm
bursts)
• hematoma (subdural and epidural…bleeding in
• To understand the patho of increased intracranial between structures in the brain)
pressure, you must understand the Monro-Kellie • hydrocephalus: buildup of CSF in the brain…
hypothesis. It deals with how ICP is affected by normally flows through the brain and spinal cord
CSF, brain’s blood, and tissue and how these and enters the bloodstream (blocked, too much
structures work to maintain cerebral perfusion is made)
pressure (CPP). • tumor: putting pressure on brain
• In a nutshell, this hypothesis says that if the • encephalitis (inflammation of brain tissue)
volume of one of these structures increases, or meningitis (inflammation of membrane
the others must decrease their volume to covering spinal cord and brain)
help alleviate pressure. When there is an • What happens with increased intracranial
increase in intracranial pressure, the body can pressure? Limited cerebral blood flow due to
temporarily compensate for it by shifting CSF to decreased cerebral perfusion from building
other areas of the brain or spinal cord (or pressure in the brain. The brain is getting
decrease it production), and alter blood volume squeezed and this leads to ischemia. All of this
going to the brain through vasocontriction, but if can lead to swelling and edema, which will
the pressure is continuous it is unable to eventually (if not treated) lead to herniation or
compensate. displacement of the brain. The displacement of
Intracranial pressure fluctuates and this can depend on the brain can compress important areas of the
many factors like: brain like the brain stem (specifically medulla
• person’s body temperature and vagus nerve).
• oxygenation status, especially CO2 and O2 levels • When CPP falls too low the body tries to
• body position increase systolic blood pressure to make
• arterial and venous pressure more blood go to the brain, but this makes
• anything that increase intra-abdominal or thoracic things worst!! During this time the arteries will
pressure (vomiting, bearing down etc.) start to dilate because of the retention of carbon
For the brain to receive proper nutrients to work it must dioxide. This causes more blood to flow to the
receive a certain amount of cerebral blood flow. This is brain but this will compress veins and limit blood
the amount of blood flowing to the brain’s tissue. It does flow to the heart. Hence, leading to more
 swelling and even more ICP. As all this • Reflex positive Babinski (toe fan out…abnormal)
progresses the patient’s signs and symptoms • Unconscious LATE
will start to become worst. Therefore, it is • Seizures
essential to know the EARLIEST signs and • Headache
symptoms (mental status changes) of increased • Emesis (vomiting) without nausea projectile
ICP. • Deterioration of motor function (hemiplegia)…
weakness on one side of the body
Signs and Symptoms of Increased ICP Nursing Interventions for Increased Intracranial
“Mind Crushed” Pressure
• Mental Status Changes ***Very earliest! Focus on preventing further increase ICP and monitoring
(restless, confused, problems performing normal ICP (if monitoring device inserted)
movements and responding to questions) “PRESSURE”
• Irregular breathing (slow down of respirations and • Position head of bed: 30 to 45 degree (helps blood
irregular…cheyne-stokes…hyperventilation return to heart), proper alignment of head
then apnea cyclic)*late (midline) NO flexion of neck (decreases venous
• Nerve changes to optic and oculomotor nerve: return) or hips (increases
double vision, swelling of optic nerve intra-abdominal/thoracic pressure)…watching
(papilledema), pupil changes (decreased, moving around in bed
increased, or unequal size), abnormal doll’s • Respiratory: Prevent HYPOXIA
eyes: oculocephalic reflex…in an unconscious and HYPERCAPNIA! When blood oxygen levels
patient open the eyes and move the head from drop or carbon dioxide levels increase,
side to side….if eyes don’t move in the opposite vasodilation occurs and this increases
direction but stay fixed in a mid-line position this intracranial pressure.
is a very bad sign….indicates brain stem - monitor blood gases, oxygen level, suctioning as
damage needed only (no longer than 15 seconds…increase ICP)
• Decerebrate or decorticate posturing or flaccid hyperoxygenated before and after
Decorticate (flexor posturing): brings upper extremities - mechanical ventilation to keep PaCO2 low 30-
to the core of the body (middle) 35 WHY? Vasoconstriction to help decrease ICP by
• adduction and flexion of arms, leg decreasing blood flow….keep the PEEP low…increases
rotated internally, feet flexed intrathoracic pressure
Decerebrate: (Extension posturing): extends upper • Systems to monitor: Glasgow Coma Scale
extremities from the body *worst of the two (remember
all the E’s in decerebrate and think EXTEND arms)
• adduction and extension of arms with
pronation, and feet flexed

• neuro checks per protocol

• ventriculostomy (external ventricular drain):
monitors ICP. It’s a catheter inserted in the area
of the lateral ventricle to assess ICP and drains
CSF during increased pressure readings.
• Cushing’s Triad: LATE SIGN…herniation of the • monitor for ICP levels greater than 20
brain stem mmHg and report to MD…..patients
- Increased systolic blood pressure (widening pulse with increased ICP are not a candidate
pressure: increase in SBP and decrease in DBP), for lumbar puncture….risk of brain
decreased heart rate, and abnormal breathing herniation.
- Increased SBP (due to body trying to get more blood to • Straining activities AVOIDED: vomiting, coughing,
the brain…thinks it’s helping) -> sneezing, Valsalva, agitation (keep environment
- Baroreceptor reflex (parasympathetic responds by calm), avoiding restraints as necessary
dropping the heart rate to decrease the blood pressure • Unconscious patient care: avoid over sedating
and there may be compression of the vagus nerve due with narcotic or sedatives, lung sounds and
to compression from the swelling in the brain -> suction as needed, immobile (skin breakdown,
- The compression on the medulla of the brain leads to monitor nutrition, at risk for renal stones,
abnormal respirations cheyne-stokes constipation, passive range of motion with
 extremities) nutrition, eye care with solutions and
ointments, maintain GI tubes for feeding
(monitor residuals….poor gastric emptying more
than 100 ml), blood clot formation (SCDs,
passive range of motion), talk to the patient as
you would a conscious patient
• Rx: Barbiturates: to help decrease brain
metabolism and BP which in turn decreases
ICP, Vasopressors/IV fluids or antihypertensive
to maintain SBP greater than 90 but less than
150, anticonvulsants meds, hyperosmotic drugs
(leads to the next point of edema management)
…….
• Edema management: dehydrating the brain (must
be done carefully…watching blood pressure and
renal function)

Mannitol: it’s a concentrated type of sugar

• When this drug enters the blood it is very
concentrated and it draws water that is pooling
in the brain back into the blood.
• This type of diuretic is filtered through the • Remember the role of the myelin sheath? This
glomerulus and not reabsorbed through structure helps with nerve transmission. The
the renal tubules, and because of this it creates myelin sheath normally functions as an insulator
an osmotic pressure that will pull water and to help nerve transmission. The myelin sheath
electrolytes (sodium, chloride) from the blood are very helpful structures that unfortunately
(won’t be reabsorbed) and be excreted out. become attacked by the immune system, and
• Watch for fluid overload (water intoxication) and when this occurs it leads to a decrease or
depletion. complete absence in nerve signaling.
• FVO: signs and symptoms of heart failure, • Why is this happening? It is important to
pulmonary edema (lung and heart sounds) remember that GBS can happen to any person
• monitor renal function, UOP, electrolytes at any age! There is currently no cure, but
• not for patients with cerebral hemorrhage or treatment can help decrease signs and
anuria (no urine output) symptoms if started within 2 weeks of
• patient will report dry mouth and thirsty…provide symptoms.
mouth care • With GBS, a previous infection usually has started
• watch fluids (IV, oral), UOP, I and O’s (retention of it all! Many patients will start to have signs and
urine?) symptoms of Guillain-Barré syndrome about 1-2
More edema management meds that may be ordered: weeks AFTER some type of viral or bacterial
• loop diuretics to remove fluid from brain and infection or one of the following:
maintain a negative fluid So, as a nurse always complete a thorough health
balance….corticosteroids history:
• respiratory illness or gastrointestinal infection
Guillain-Barré Syndrome (especially Campylobacter jejuni)
What is Guillain-Barré syndrome? It’s an autoimmune • Vaccine (swine flu etc.)
neuro condition where the immune system attacks the • Surgery
nerves in the peripheral nervous system and cranial • Epstein-Barr virus HIV/AIDS, flu infection
nerves.
What specifically is the immune system Various types of Guillain-Barré syndrome:
attacking? The immune system, which was attacking Cases can vary from mild to very severe.
the illness, starts to confuse the cranial and PNS nerves • Acute inflammatory demyelinating
for the illness. Therefore, the immune system begins to polyneuropathy (AIDP): most common type
attack the myelin sheath (demyelination occurs) on the and what we will concentrate on in this lecture. It
nerve cell. starts with paralysis/weakness/tingling
sensation in the LOWER EXTREMIES
(symmetrically) and migrates upward over
time. It can be so severe the person will
experience paralysis.
Mnemonic for Guillain-Barré syndrome: “GBS”
• Gradual
• Blocking of
• Sensation
There is another type called: Miller Fisher Syndrome. Signs and Symptoms associated with autonomic
Eye paralysis is usually the first sign and symptom with dysfunction:
this type. • Inability to regulate body temperature
• blood pressure issues (orthostatic hypotension
What is happening in GBS? and paroxysmal hypertension)
• GBS: Gradual Block of Sensation • cardiac dysrhythmias
• Let’s talk Nerves (which helps explain signs Cranial nerves: In addition, there can be cranial nerve
and symptoms) involvement, as it gradually migrates up to the area of
• Peripheral nervous system nerves are the brain stem where the cranial nerves are located. This
involved! Therefore, we’re talking about all the leads to vision problems, paralysis of the face, issues
nerves outside the brain and spinal cord. swallowing, trouble speaking etc.
• The PNS creates a connection between our
brain/spinal cord to the rest of our body (so our • Let’s look at a typical scenario: A patient is 35
limbs, muscle, and some of the organs are years old and has no pertinent information in
involved). AIDP is the most common type of their health history other than that they were sick
GBS in the U.S. about 2 weeks ago with a GI illness. However,
• Most patients start to have this weird tingling or they’ve recovered from it but now are presenting
numbness sensation (PARAESTHESIA) in their with this tingling, numbness, and weakness in
feet, which will gradually spread upward the feet (called paresthesia) and it’s making
(symmetrically). Paralysis, absent reflexes, and walking difficult. They tell you they haven’t
loss of muscle tone is likely to follow the injured themselves and the sensation is getting
paresthesia. worst.
• The PNS creates a connection between our • This is how some patients may present with GBS
brain/spinal cord to the rest of our body (so our (but this syndrome is just starting).
limbs, muscle, and some of the organs are • As time goes on, you will find that these signs and
involved). AIDP is the most common type of symptoms start to migrate up and are
GBS in the U.S. symmetrical in origin. The patient’s reflexes will
• Most patients start to have this weird tingling or become majorly diminished or absent. This will
numbness sensation (PARAESTHESIA) in their affect the legs, arms, chest muscles used for
feet, which will gradually spread upward breathing, face/eyes/swallowing ability (cranial
(symmetrically). Paralysis, absent reflexes, and nerves), and in severe cases the autonomic
loss of muscle tone is likely to follow the nervous system.
paresthesia. • As more time goes on the signs and symptoms go
• As a side note: It’s very important to note from weakness to paralysis (ex: paralyzed
that GBS PEAKS in about 2 weeks with its from neck down), lose muscle tone, absent
severity of symptoms, and then slowly recovery reflexes, facial paralysis, issues swallowing,
occurs (remylenation of the myelin sheath). talking, weak cough (need suctioning, short of
Nurse: reassure the patient and always breath, reports they can’t breathe in very well)
communicate with them because patients who and autonomic issues.
experience GBS are extremely fearful. • ****Respiratory system is a major focus for the
• In addition, it takes about 1-2 years for the patient nurse!!! When this system is affected, most
to return to baseline (most patients have to patients will need to be intubated or have a
complete some type of physical rehab after tracheostomy for assistance to breathe. Monitor
experiencing GBS due to the complications for signs and symptoms that this system is being
associated with it in regards to muscle atrophy affected.
and nerve damage). • These signs and symptoms peak at about 2
• As the demyelination spreads, it can start to affect weeks from when the symptoms started. Then
the autonomic nervous system of the PNS. slowly the signs and symptoms (remyelination of
Remember the PNS can be separated into the myelin sheath) start to resolve slowly. Most
somatic nervous system (controls voluntary patients can make a full recovery within 1-2
movement functions) and autonomic nervous years, but there are usually major complications
system (involuntary functions). afterwards due to paralysis that puts the patient
• ***In severe cases of GBS, the autonomic on a long road to recovery.
system (parasympathetic and sympathetic • One important thing to point out that although the
nervous system) can be affected. Therefore, patient is experiencing paralysis or weakness,
we’re talking about the nerves that regulate our many patients will experience severe pain like
blood pressure, heart rate/rhythm, temperature, muscle pain/ cramps. Exact reason not
vision, GI (constipation… decrease in motility of known….may be due to nerve damage. But it’s
the GI system) and renal (retention of urine due very important as the nurse to evaluate the
to sphincter issues). patient for pain using some type of
communication technique.
 • However, because of severity of the muscle motility )and may experience an increase in
weakness most patients end up needing to be gastric residuals so always check prior to a new
intubated (as stated above), develop infection feeding)….most patients will have a feeding tube
(pneumonia from aspiration or ventilator • Management of airway with mechanical ventilation
acquired), at risk for blood clots and pressure • Pain control
injuries due to immobility, severe weight loss • PT to work with and ROM to prevent muscle
from nutrition issues, and will need intense wasting and contractures
physical therapy. • Keep patient informed (this is scary…you usually
have a once healthy person now experiencing
How is Guillain-Barré syndrome Diagnosed? severe paralysis and can’t breathe on their
• Electromyography and nerve conduction studies: own….make sure you have some way to
assesses for demyelination of nerves by communicate because they will most likely be
determining muscle’s ability to respond to nerve aware of everything going on and reassure this
stimulation is most likely temporary)
• Lumbar puncture: elevated
protein without elevated white blood cells. Treatments for Guillain-Barré syndrome
Nursing Role for Lumbar Puncture: • Not a cure but helps speed up recovery:
• Before: empty bladder administered within 2 weeks from onset of
• During: position lateral recumbent with knees up symptoms….if greater than this time frame…
to abdomen and chin to the chest doesn’t really help decrease signs and
• Post: lay flat per MD order (helps decrease symptoms
headache)…head not to be elevated, patient • PLASMAPHERESIS: machine that will filter the
needs fluids to help replenish fluid taken (help blood to remove the antibodies from the plasma
decrease a headache as well) that are attacking the myelin sheath (help
decrease signs and symptoms not a cure)
• Immunoglobulin therapy: IV immunoglobulin
from a donor given to the patient to stop the
antibodies that are damaging the nerves.

SEIZURES

Nursing Interventions for Guillain-Barré Syndrome

Focus: Respiratory, blood clots (immobility) risk for PE
and DVTs, heart rhythm, blood pressure issues,
nutrition, infection (urinary retention and lung from vent
or pneumonia), pain, pressure injuries, atrophy of
muscles, extreme fear
• Collect a detailed health history
• Monitor for progression of the syndrome and if the
patient is getting worst: • What are seizures? Seizures occur
• Spread of the paresthesia or paralysis? when abnormal electrical signals are being
• Change in reflexes? rapidly fired for neurons in the brain. This can
• RESPIRATORY status (is it hard for the patient to happen throughout the brain affecting both sides
talk, feel like they can’t breathe, can’t clear (generalized seizure) or being located in a
secretions, decrease respiratory rate, always specific area of the brain (partial or focal
having to suction patient?) seizure).
• Have airway management equipment at
bedside
• Evaluate their swallowing…at risk for aspiration
• Communication….patient is aware but can’t
communicate…use a white board
• Pain (severity and treat accordingly)
• Pressure injuries due to immobility: need frequent
turning to prevent pressure injuries
• Prevent blood clots (SCDs, anticoagulants)
• Intake and output (may need catheter to drain
urine due to urinary retention) • Seizures can occur in anyone (children and
• Eye care due to facial paralysis (keep eyes moist adults) due to a severe acute condition, such as
with drops etc.) a high fever, illness (especially central nervous
• Nutrition: assess bowel sounds (at risk for system types like bacterial meningitis),
paralytic ileus), constipation (decrease in gastric hypoglycemia, acid-base imbalances
 like acidosis, alcohol withdraw, brain tumor etc. • Usually lasts no more than 3
Once the condition is corrected the seizures minutes…..at risk for status
tend to stop. epilepticus with this type of seizure
However, some patients can experience epilepsy. • ****if greater than 5 minutes or
Epilepsy is where the patient has frequent seizures due having multiple seizures in a
to a chronic condition of some type like congenital brain row…activate emergency
defect, stroke, traumatic brain injury, long-lasting effects response team (will need
of an infection etc immediate treatment to stop
seizure (more on this in the
WHAT HAPPENS IN THE BRAIN DURING A SEIZURE nursing interventions)
(watch video) • Post ictus (duration: hours to days): this
is the recovery period: patient will feel
Simplified Patho of Seizures very tired, extremely sore from muscle
• In the brain, our neurons are tasked with handling stiffening and jerking, can’t remember
and transmitting information. There are two what happened.
types of neurons. These are excitatory and • Tonic seizure: (stiffening of the body….risk for
inhibitory neurons. falling) or Clonic seizure: (jerking….can be
• Just like their name says, excitatory symmetrical or asymmetrical )
neurons produce “an action” or cause • Absence Seizure (formerly called petit-mal)
“excitement” by releasing a neurotransmitter Most common in pediatric patients and Hallmark is a
called glutamate (this is an excitatory staring like state
neurotransmitter). • It will be like the child is just
• Inhibitory neurons “stop an action” or cause daydreaming but can’t be snapped out
inhibition by releasing an inhibitory of it….can go unnoticed by others for a
neurotransmitter called GABA. while because it short and the child
• ***For seizure activity not to occur in a healthy won’t remember it. The person will look
brain, there needs to be a proper confused and won’t be able to talk
balance between these two types of neurons. If during the even.
there is an imbalance of excitatory neurons vs. Very short…..seconds
inhibitory neurons, seizures will occur. For Post Ictus: immediate…doesn’t remember staring off
example, if there is not enough GABA • Atonic (drop attacks):
(remember this is the inhibitory neurotransmitter) - “A” means without and when you put the word tonic
being released, too much excitation will occur after it the meaning is: WITHOUT MUSCLE TONE
leading to seizure activity. • The patient goes limp and falls if
• This is to help you understand how some of the standing or slumps over if sitting…at risk
anti-seizure drugs work to treat seizures. For for head injury (may need helmet)
instance, barbiturates stimulate GABA - Usually not aware during event….post ictus:
receptors which help control excitation and immediate…regains consciousness
decreases seizure activity (more about • Myoclonic:
medications in the next slides). Quick duration of jerking of the muscles
Types of Seizures Patient usually aware and conscious (this is what makes
**remember these types, especially their it different from a clonic seizure)
characteristics, expected duration, post ictus phase Very short….few seconds
etc. • Focal (also called partial): affects a specific
Generalized: seizure is affecting both parts of the part of the brain
brain Two types: know the main differences which is that
• Tonic-clonic (formerly called grand -mal): most with focal onset aware (simple partial) the patient
common type of generalized seizure is AWARE of their surroundings but with focal impaired
• May experience AURA (warning a awareness (complex partial) the patient is NOT
seizure is about to happen) aware of their surroundings AND will have motor
• Loses consciousness (at risk for injury) symptoms called automatisms.
• Will experience a tonic phase: - Focal Onset AWARE (simple partial): symptoms vary
body stiffens (may bite inside of depending on where the seizure is located
the cheek or tongue….may see It tends to be a small area of a lobe…but patient
blood leaving mouth with is AWARE…example: occipital region the person may
foaming of saliva), breathing have vision changes
stops followed by cyanosis) Also sometimes called an aura too because it can
• Then a clonic phase: recurrent happen right before focal impaired awareness (complex
jerking (spasm and relaxation partial)
back-to-back) of extremities - Focal Impaired AWARENESS (complex partial):
(patient may have incontinence alternation in awareness and has motor symptoms
of stool or/and urine) Temporal lobe most commonly involved
Focal onset aware (aura) can happen before it • bed in the lowest position
- Automatisms present: this is where they are • remove objects that can cause injury
performing an action without knowing they are doing it (remove any restrictive clothing or items
like lip smacking, rubbing hands together, or grasping for the patient may be wearing….eye
something that isn’t there glasses etc. )
• Assess if your patient has a history of seizures in
Stages of Experiencing a Seizure the past and if so what type of seizure, ask if the
We can divide how a person experiences a seizure into patient experiences prodromal signs and
stages (it varies depending on the seizure type, so symptoms or an aura before the seizure, how
remember that) long does the seizure last?
Prodromal: when symptoms start to appear prior to the • If patient is able to report prodromal or aura….help
big event (hence seizure) patient prepare by getting the patient in a safe
• can start days before a seizure happens position by lying down on their side.
• mood changes (depression, anger, issues
sleeping, anxiety, GI and urinary issues etc.) What to do when your patient has a seizure?
Aura: doesn’t happen with all types Protect patient if they are standing-up or sitting down by:
• happens at the very beginning of the seizure (what • gently lying the patient down and turning them
type: focal seizures OR in a tonic-clonic onto their side. WHY? This helps prevent the
seizure) tongue from covering the airway and helps
• happens within seconds to minutes before a saliva and blood drain from the mouth.
seizure • DO NOT restrain patient or try to hold the patient
• many times it gives the patient time to prepare self down
for seizure. As the nurse (if you are present) • Protect their head and extremities (pillow and bed
help the patient lay down onto their side with a pads will help with this)
pillow under the head. • DO NOT put anything in the patient’s mouth
• Symptoms vary among patients but can include: • Remove anything that can impede breathing or
sudden weird smell or taste, déjà vu feeling, break (eye glasses, tight clothing etc. ).
feeling anxious like something bad is about to ****Questions to be asking yourself during the
happen, altered vision (lights or spots in vision) seizure****
or hearing (hallucination type sounds or • Note the time it started and time it
increased ability to hear sounds), dizzy (different stopped (VERY IMPORTANT: if greater than 5
for every person), inability to speak etc. minutes or another seizure happens…THINK:
Ictus: (word means seizure) this is the actual seizure status epilepticus and activate the emergency
• Usually lasts anywhere from 1 to 3 minutes system response team. You will notify the MD of
• Time the seizure the seizure regardless because the seizure
• seizures greater than 5 minutes or if the needs to be investigated….is the patient’s drug
patient starts having seizure back-to- level for anti-seizure medications too low?
back, the patient may be • When the seizure started what was the
experiencing status epilepticus (will patient’s behavior right before and during
need medical care and medication to it? (did they cry out, become confused, report an
make the seizure stop…it will unlikely aura, become unconscious) and the
stop on its own) characteristics of the body movements (if any)
Post Ictus: (after the seizure) brain is going to rest and presented at the beginning and throughout the
recover from the seizure seizure…..stiffening of the whole body or just the
• usually last hours to days (tonic clonic)…..for extremities and then jerking or just jerking, was it
some patients it is immediate (absence) on just one side or both sides of the body….be
• may feel extremely tired, sleepy, confused, sure to be as detailed as possible…this helps
headache etc. the healthcare team determine what type of
seizure this was and what treatment may be
Nursing Interventions for Seizures needed
• Assess risk factors for seizure (remember any • Did the patient become incontinent of urine or
patient can experience this if any of the stool? Oxygen status (cyanosis present)
causes mentioned above are presenting… Your role during the Post Ictus stage:
you want to be prepared. If risk factors Note the time the seizure stopped and how the patient is
present initiate seizure precautions: behaving afterwards:
• Seizure precautions may include: • Are they tired (let them sleep and rest), confused,
• at bedside have suction and oxygen can’t think or talk, have a headache (ask where
ready it is located and pain rating), has any injuries
• IV access (to given anti-seizure (some patients may bite their tongue or cheek)
medication, if needed) • Maintain airway (suction, administer oxygen)
• padded side rails • If a tonic-clonic seizure, the patient will be very
• pillow under head (to protect head) sleepy, won’t remember what happened.
 • Assess vital signs and neuro status: pupils, Benzodiazepines: absence seizures, tonic clonic, focal
reflexes, is patient confused or oriented • Diazepam or Lorazepam: status epilepticus (fast
• Clean patient if incontinence was experienced. acting)
• Document and report it to the physician… is this • Very drowsy, tolerance can develop where it
your patient’s first seizure, are they on anything isn’t as effective, impair liver (monitor liver
for seizures (is drug level not therapeutic….may studies)
need to draw a drug level if ordered by MD) • Reversal agent: Flumazenil (*used with extreme
EEG may be ordered: caution due to its risks)
What’s an EEG (Electroencephalogram)?: assesses Valproates: Valproic Acid
brain activity all types….monitor liver, WBC and platelets, GI issue
• Painless
• Hold seizure medications or medications that are Other treatments:
stimulants or depressants prior to EEG (these • surgery: to remove an area of the brain that is
medications can prevent the proper assessment causing the seizure….example: focal seizures
of abnormal brain waves associated with a that arise from temporal lobe (temporal
seizure) lobectomy)
• No caffeine products (a stimulant) 8 hours before • Meds not working: placement of a vagus nerve
• Can eat before stimulator: an electrical device that sends
• Make sure patient’s hair is clean (needs good electrical signals to the vagus nerve
attachment to scalp) • Ketogenic diet (used in pediatric patient who have
• Different types of EEGs: some patients will need epilepsy): high fat, low carb, diet….used when
to experience sleep deprivation before the test seizures not controlled by medication
by not sleeping the night before the test or only
part of the night….always ask about this
• Education to patient about factors that can
trigger a seizure:

Medications/Treatments
Medications treat based on type of seizure:
Barbiturates: Phenobarbital (used tonic-clonic or focal
seizures & status epilepticus)
• stimulates GABA receptors & this helps inhibitory
neurotransmission
• side effects: drowsiness, uncoordinated
movements (ataxia) etc.
• watch for: respiratory depression and hypotension
• drug level 15 to 40 mcg/mL
Hydantoins: Phenytoin (used in tonic-clonic or focal
seizures)
• watch the gums: will enlarge and easily bleed
(called gingival hyperplasia….teach about
good mouth care
• may cause bone marrow suppression (watch
platelets and WBCs)
• tell patient to watch for rash or Steven-Johnson’s
Syndrome and to REPORT it to their doctor
immediately
• don’t give with milk or antacids (interferes with
absorption)
• 10 to 20 mcg/mL