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Neurological 6

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