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Neurological 5

  1. Management
    1. expected outcome to improve strength and endurance
    2. pharmacologic
      1. anticholinesterase agents: pyridostigmine (mestinon), neostigmine (prostigmin)
      2. corticosteroid therapy
      3. immunosuppressants: azathioprine (imuran)
    3. thymectomy(illustration)
    4. plasma exchange
    5. myasthenic crisis management
      1. crisis usually follows stressor or during dosage changes
      2. signs: sudden inability to swallow, speak, or maintain patent airway
      3. cholinergic crisis may follow over dosage of medication
      4. positive edrophonium (tensilon) test signals myasthenia
      5. if negative endophronium test, client has not myasthenic but cholinergic crisis, so treat with atropine
      6. ventilatory support as indicated
  2. Nursing interventions
    1. identify aggravating factors, such as:
      1. infection
      2. stress
      3. changes in medication regime
    2. if client is in crisis: provide care of the client on ventilatory support 
    3. give medications as ordered and on time
    4. help with ADL and feeding as indicated
    5. provide
      1. emotional support
      2. adequate rest periods
      3. care of the surgical client
    6. teach client
      1. energy conservation techniques
      2. medications, expectations and side effects
      3. signs of impending crisis, both myasthenic and cholinergic
      4. to avoid stressors
  3. Seizure Disorders
  4. Definition/etiology
    1. Sudden, transient alteration in brain function
    2. Disorderly transmission of electrical activity in the brain
    3. Causes
      1. cerebral lesions
      2. biochemical alteration
      3. cerebral trauma
      4. idiopathic
  5. A classification of seizure typespartial, simple, complex, generalized
    1. Partial seizures
      1. focal motor
      2. seizure activity only in specific parts of the brain
      3. usually client remains conscious
    2. Simple with findings associated with
      1. motor activity
      2. special sensory feelings
      3. autonomic activity
      4. psychic issues
      5. psychomotor actions
      6. no loss of consciousness
    3. Complex
      1. impairment of consciousness
      2. secondarily generalized
      3. progressing to generalized tonic-clonic
    1. Generalized seizures: eight types
      1. petit mal - called absence seizures
      2. myoclonic
        1. sudden, uncontrollable jerking movements of one or more extremities
        2. usually occurs in the morning
      3. clonic
        1. characterized by violent muscle movements
        2. hyperventilation
        3. face contortion
        4. excessive salivation
        5. diaphoresis
        6. tachycardia
      4. tonic
        1. first, client loses consciousness suddenly and muscles contract
        2. body stiffens in opisthotonosposition (illustration)
        3. jaws clenched
        4. may lose bladder control
        5. apnea with cyanosis
        6. pupils dilated and unresponsive
        7. usually lasts less than a minute
      1. grand mal: most common type
        1. tonic-clonic movements
        2. may be preceded by prodromal
        3. lasts two to three minutes
        4. after clonic phase, client is unresponsive for about five minutes
        5. arms, legs go limp
        6. breathing returns to normal
        7. possible disorientation or confusion for sometime afterwards
        8. possible headache and fatigue afterwards
      2. atonic: sudden loss of postural muscle tone with collapse
      3. unclassified seizures
      4. status epilepticus
        1. rapid sequence of seizures without interruption
        2. medical and nursing emergency
        3. client in postictal state when next seizure begins
        4. sometimes occurs if a sudden stop of maintenance doses of anticonvulsants
        5. if cerebral anoxia occurs, brain damage or death can follow
        6. risk for severe organ and muscle hypoxia
    1. Diagnostics

e.                  by the event itself - see above

f.                   history and physical exam

g.                  electroencephalogram (EEG)

h.                  computerized tomogram (CT) scan

      1. Management
        1. expected outcomes: to control the seizure activity and prevent complications
        2. correction of underlying problem
        3. medications
          1. benzodiazepines, I.V. such as diazepam (valium), lorazepam (ativan) for active seizures
          2. hydantoin anticonvulsants such as phenytoin (dilantin) - maintenance
          3. barbiturates such as phenobarbitol - maintenance
          4. succinimides such as ethosuximide (zarontin) - maintenance
      2. Nursing interventions
        1. administer medications as ordered
        2. seizure care 
        3. seizure precautions 
        4. teach client
          1. about medication effects, interactions, and side effects
          2. to learn when a seizure may be triggered
          3. techniques to reduce stress
          4. seizure care at home or at work
          5. to wear medic-alert jewelry
          6. if in public area, after the tonic phase turn client to side