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Neurological 6
- Headache
- Definition
- Pain located in upper region of the head
- One of the most common neurologic complaints
- Classifications
- Recurrent migraine headache
- onset during adolescence or early adulthood
- familial
- involves unilateral, throbbing pain
- subtypes
- classic migraine
- common migraine
- cluster headache
- hemiplegic headache
- ophthalmoplegic headache
- Recurrent muscular-contraction headache (pressure, tension headache)
- most common form of headache
- may be direct result of stress, anxiety or depression
- Nonrecurrent headaches
- occur with systemic infections and are usually associated with fever
- occur as the result of a lesion, after an invasive spinal cord procedure such as a lumbar puncture, or subarachnoid bleed
- caused by increased intracranial pressure
- Findings
- Vary by type of headache
- May include throbbing, nausea, vomiting, visual disturbance, tenderness, neck stiffness, and focal neurological signs
- Diagnostics
- History and physical exam
- Computing tomogram (CT) scan
- Magnetic resonance imaging (MRI)
- Management of headaches
- Expected outcomes: to alleviate pain and treat underlying cause
- Vasoconstriction by pressure or cold
- Management of migraine
- nonnarcotic analgesics: aspirin, acetaminophen (tylenol), ibuprofen
- narcotic analgesics: codeine, meperidine (demerol)
- alpha-adrenergic blocking agentblocker: ergotamine tartrate (ergostat) without or with caffeine
- steroids: dexamethasone (decadron)
- prophylactic treatment with beta-adrenergic blocking agents, serotonin antagonists, antidepressants, imipramine (tofranil)
- avoid headache-precipitating foods such as MSG, tyramine, or milk products, or sudden stopping of caffeinated drinks
- Management of tension headaches
- nonnarcotic analgesics
- muscle relaxants
- prophylactically: antidepressants and/or doxepin (sinequan)
- Management of cluster headaches
- narcotic analgesics: codeine sulfate
- alpha-adrenergic blocking agentblocker: ergotamine tartrate (ergostat)
- prophylactically with serotonin antagonists
- Nursing interventions
- Suggest a quiet, dark environment
- Manage pain by prompt medication administration or other comfort measures
- Help client identify precipitating factors and actions for prevention
- Keep NPO until nausea and vomiting subside
- Teach client
- expected medication actions and side effects
- alternatives for pain relief including referrals for alternative approaches
- to avoid or minimize trigger factors
- to keep a headache diar
- Head Trauma (Illustration 1 Illustration 2 Illustration 3)
- Classifications
- Closed versus open injury
- closed is nonpenetrating; no break in integrity of skull
- open injury: skill broken with brain exposed
- Severity
- mild: only momentary loss of consciousness with no neurological sequelae
- moderate: momentary loss of consciousness with a change in neurological function which is usually not permanent
- severe: decreased LOC with serious neurological impairment and sequelae
- Types of skull fractures
- Linear: simple break in bone; no displacement of skull
- Depressed: part of skull is pushed in
- Basal: at base of skull; may extend into orbit or ear; ear or nose may leak CSF; most difficult to verify by x-ray
- Concussion: temporary loss of neurologic function but complete recovery
- Types of bleeding
- Epidural hematoma
- usually something lacerated the blood vessels of the middle meninges
- since this is arterial bleeding, the risk of death is greatest
- client commonly looses consciousness after injury then is lucid , then LOC drops quickly with the next 24 hours
- Subdural hematoma
- something has lacerated the blood vessels crossing the subdural space
- acute: findings surface in 24 to 72 hours after injury with rapid neurologic deterioration
- subacute: findings surface 72 hours to two weeks after injury with a slower progression of deterioration
- chronic: gradual clot formation over time, possibly months with minimal deterioration
- Progression of skull fracture injury
- Onset: contusions and lacerations of nerve cells
- Gradual demyelinization of affected nerve fibers results in neuron death
- Scarring: meninges adheres to injured area of brain
- Complications
- Edema
- results in increased intracranial pressure
- results directly from cerebral ischemia, anoxia, and hypercapnia
- Syndrome of inappropriate anitdiuretic hormone (ADH) (SIADH)
- too much ADH is produced
- water is excessively retained - hemodilution
- urinary output decreases; urine specific granity increases effect
- more common in the chronic phase of care after a head injury
- Diabetes insipidus (DI)
- DI results from a decrease release of ADH and body excretes too much fluid
- the increase in urinary output results in a low specific gravity
- more common in the acute phase of head injury
- Stress ulcer
- head injuries activate both the sympathetic and parasympathetic systems
- stimulation of sympathetic system leads to gastric ischemia from vasoconstriction
- stimulation of parasympathetic system leads to increased release of hydrochloric acid (HCL) into the stomach
- steroid therapy may contribute to the development of ulcers since steroids increase HCL acid
- Seizure disorders
- Infection in brain, lungs, urinary system
- Hyperthermia or hypothermia
- Findings of head trauma
- Degree of neurological damage varies with type and location of injury
- Restlessness and irritability - initially
- Decreased LOC - lethargy, difficulty with arousal
- Headache
- Nausea and vomiting - projectile vomiting indicates increased ICP
- Diagnostics
- History and physical exam
- Computerized tomogram (CT) scan
- Magnetic resonance imaging (MRI)
- Electroencephalogram (EEG)
- Management
- Expected outcomes: to reduce or minimize increases in intracranial pressure and protect the nervous system
- Medications for increased ICP
- osmotic diuretics; mannitol (osmitrol) - IV drip or push
- steroids: dexamethasone (decadron) - IV push
- barbiturate coma may be induced to treat refractory increased intracranial pressure
- Surgical correction of underlying cause
- Treatment for evident findings: seizures, fever, infection
- Therapy
- speech
- physical
- occupational
- behavioral
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