NUR 420 EXAM 3

Nursing Care After the Seizure

-Keep the patient on one side to prevent aspiration. -Make sure the airway is patent. -On awakening, reorient the patient to the environment. -If the patient is confused or wandering, guide the patient gently to a bed or chair. -If the patient becomes agitated after a seizure (postictal), stay a distance away, but close enough to prevent injury until the patient is fully aware.

Urine Specific Gravity

1.010-1.025

The minimum amount of urine needed to rid the body of normal metabolic waste products is

400 mL in 24 hours or 0.5 mL/kg/hr.

Chronic SDH

A chronic SDH can develop from seemingly minor head injuries and is seen most frequently in older adults who are prone to this type of head injury due to brain atrophy, which is a consequence of the aging process Time between injury and onset of symptoms can be lengthy (e.g., 3 weeks to months) A chronic SDH can resemble other conditions—for example, it may be mistaken for a stroke. Bleeding is less profuse; blood within the brain changes in character in 2 to 4 days, becoming thicker and darker; clot breaks down and has the color and consistency of motor oil in few weeks; eventual calcification or ossification of the clot takes place. Symptoms:severe headache, which tends to come and go; alternating focal neurologic signs; personality changes; mental deterioration; and focal seizures The treatment: surgical evaluation for evacuation of the clot. Consideration must be made for reversal of coagulopathies and iatrogenic anticoagulation The operative procedure may be carried out through multiple burr holes, or a craniotomy may be performed for a sizable subdural mass that cannot be suctioned or drained through burr holes.

Cushing's response (reflex)

A clinical phenomenon known as the Cushing's response (or Cushing's reflex) is seen when cerebral blood flow decreases significantly. Vasomotor center triggers an increase in arterial pressure in an effort to overcome the increased ICP. It is a late sign requiring immediate intervention; however, perfusion may be recoverable if the Cushing's response is treated rapidly.

Migraine

A complex of symptoms characterized by periodic and recurrent attacks of severe headache lasting from hours to days in adults. Cause: has not been clearly demonstrated, but it is primarily a vascular disturbance that has a strong familial tendency. The typical time of onset is at puberty, and the incidence is higher in women than men Subtypes: migraine with and without aura. Most patients have migraine without an aura.

Assessment of Headache

A detailed description of the headache is obtained Include medication history and use The types of headaches manifest differently in different persons and symptoms in one individual may also may change over time Although most headaches do not indicate serious disease, persistent headaches require investigation Persons undergoing a headache evaluation require a detailed history and physical assessment with neurologic exam to rule out various physical and psychological causes Diagnostic testing may be used to evaluate underlying cause if there are abnormalities on the neurologic exam

Postrenal AKI

AKI usually results from obstruction distal to the kidney by conditions such as renal calculi, strictures, blood clots, benign prostatic hypertrophy, malignancies, and pregnancy. Pressure rises in the kidney tubules, and eventually the GFR decreases. Common causes of each type of AKI Postrenal Failure Urinary tract obstruction -Benign prostatic hyperplasia -Blood clotsCalculi (stones) -Strictures -Tumors

acute renal failure (ARF)

ARF is an abrupt, rapid decline in renal function. It is usually caused by trauma, sepsis, poor perfusion, or medications. ARF can cause hyponatremia, hyperkalemia, hypocalcemia, and hyperphosphatemia. Diet therapy for ARF is dependent upon the phase of ARF and its underlying cause.

Autonomic Dysreflexia

Acute life-threatening emergency that occurs as a result of exaggerated autonomic responses to stimuli that are harmless in people without SCI. It occurs only after spinal shock has resolved S/S: severe, pounding headache with paroxysmal hypertension, profuse diaphoresis above the spinal level of the lesion (most often of the forehead), nausea, nasal congestion, and bradycardia. T6 (the sympathetic visceral outflow level) after spinal shock has subsided The sudden increase in blood pressure may cause retinal hemorrhage, hemorrhagic stroke, myocardial infarction, or seizures A number of stimuli may trigger this reflex: ****distended bladder (the most common cause); distention or contraction of the visceral organs, especially the bowel (from constipation, impaction); or stimulation of the skin (tactile, pain, thermal stimuli, pressure ulcer). Remove the triggering stimulus and to avoid the possibility of serious complications

AKI medical management: tissue perfusion

Adequate renal blood flow in patients with prerenal causes of AKI may be restored by IV fluids or transfusions of blood products. Hypovolemia (secondary to hypoproteinemia): infusion of albumin may be prescribed. Dialysis: initiated to prevent complications of AKI, such as hyperkalemia, metabolic acidosis, pericarditis, and pulmonary edema. Dialysis: corrects many biochemical abnormalities; allows for liberalization of fluid, protein, and sodium intake; diminishes bleeding tendencies; and promotes wound healing. -Hemodialysis (a procedure that circulates the patient's blood through an artificial kidney [dialyzer] to remove waste products and excess fluid) Peritoneal dialysis: (PD; a procedure that uses the patient's peritoneal membrane [the lining of the peritoneal cavity] as the semipermeable membrane to exchange fluid and solutes), or a variety of continuous renal replacement therapies (CRRTs) (methods used to replace normal kidney function by circulating the patient's blood through a hemofilter)

Postrenal Medical Management

Alleviate obstruction May need stent Postrenal conditions are usually resolved with the insertion of an indwelling bladder catheter, either transurethral or suprapubic. Occasionally, a urethral stent may have to be placed if the obstruction is caused by calculi or carcinoma.

ESRD Gastrointestinal Symptoms

Ammonia odor to breath ("uremic fetor") Anorexia, nausea, and vomiting Bleeding from gastrointestinal tract Constipation or diarrhea Hiccups Metallic taste Mouth ulcerations and bleeding

Important Stroke Terms:

Aphasia: unable to speak (comprehending or producing it) -Receptive Aphasia: unable to comprehend speech (Wernicke's area) -Expressive Aphasia: comprehends speech but can't respond back with the correct words, if at all (Broca's area) -Mixed Aphasia: combination of the two types of aphasia. -Global Aphasia: complete inability to understand speech or produce it. Dysarthria: unable to hear speech clearly due to weak muscles (hard to understand the patient's speech....it may be slurred) Apraxia: can't perform voluntarily movements (winking/moving arm to scratch an itch) even though muscles function is normal. Agraphia: loss the ability to write Alexia: loss the ability to read...doesn't understand or recognize the words Agnosia: doesn't understand sensations or recognize known objects or people Dysphagia: issues swallowing (weak muscles) Hemianopia: limited vision in half of the visual field

acute SDH

Approximately 50% of brain injuries and 60% of deaths in patients with brain injuries result from acute SDHs and are associated with major head injury involving contusion or laceration. Signs and symptoms: include changes (LOC), pupillary signs, and hemiparesis. There may be minor or even no symptoms with small collections of blood. Coma, increasing blood pressure, decreasing heart rate, and slowing respiratory rate are all signs of a rapidly expanding mass requiring immediate intervention. If the patient can be transported rapidly to the hospital, an immediate craniotomy is performed to open the dura, allowing the subdural clot to be evacuated. Successful outcome also depends on the control of ICP and careful monitoring of respiratory function The mortality rate for patients with acute SDH is high because of associated brain damage

Cerebral Response to Increased Intracranial Pressure

As ICP rises, compensatory mechanisms in the brain work to maintain blood flow and prevent tissue damage. The brain can maintain a steady perfusion pressure if the arterial systolic blood pressure is 50 to 150 mm Hg and the ICP is less than 40 mm Hg. Changes in ICP are closely linked with cerebral perfusion pressure (CPP). Autoregulate fails and decompensation (ischemia and infarction) Significant changes in mental status and vital signs. Cushing's Triad

ESRD

As renal function declines, the end products of protein metabolism (normally excreted in urine) accumulate in the blood. Uremia develops and adversely affects every system in the body. The greater the buildup of waste products, the more pronounced the symptoms. The rate of decline in renal function and progression of ESKD is related to the underlying disorder, the urinary excretion of protein, and the presence of hypertension. The disease tends to progress more rapidly in patients who excrete significant amounts of protein or have elevated blood pressure than in those without these conditions.

AKI Assessment and Diagnostic Findings

Assessment and Diagnostic Findings -changes in the urine, diagnostic tests that evaluate the kidney contour, and a variety of laboratory values -a normal volume, hematuria may be present, and the urine has a low specific gravity (compared with a normal value of 1.010 to 1.025). One of the earliest signs of tubular damage is the inability to concentrate the urine Prerenal azotemia: have a decreased amount of sodium in the urine (less than 20 mEq/L) and normal urinary sediment. Patients with intrarenal azotemia usually have urinary sodium levels greater than 40 mEq/L with urinary casts and other cellular debris. Ultrasonography: is a critical component of the evaluation of patients with kidney disease. -A renal sonogram or a CT or MRI scan may show evidence of anatomic changes. -The BUN level increases steadily at a rate that depends on the degree of catabolism (breakdown of protein), renal perfusion, and protein intake. -Serum creatinine levels are useful in monitoring kidney function and disease progression and increase with glomerular damage. -With a decline in the GFR, oliguria, and anuria, patients are at high risk for hyperkalemia. -Protein catabolism results in the release of cellular potassium into the body fluids, causing severe hyperkalemia

ESRD assess neuro

Asterixis-flapping tremor Behavior changes Burning of soles of feet Confusion Disorientation Inability to concentrate Restlessness of legs Seizures Tremors Weakness and fatigue

Ischemic Stroke Risk Factors

Asymptomatic carotid stenosis Atrial fibrillation Diabetes (associated with accelerated atherogenesis) Dyslipidemia Excessive alcohol consumption Hypercoagulable states Hypertension (controlling hypertension, the major risk factor, is the key to preventing stroke) Migraine Obesity Sedentary lifestyle Sleep apnea Smoking

Cranial arteritis

Begins with general manifestations, such as fatigue, malaise, weight loss, and fever. Clinical manifestations associated with inflammation (heat, redness, swelling, tenderness, or pain over the involved artery) usually are present. Sometimes a tender, swollen, or nodular temporal artery is visible. Visual problems are caused by ischemia of the involved structures Found in the older population, reaching its greatest incidence in those older than 70 years of age. Inflammation of the cranial arteries is characterized by a severe headache localized in the region of the temporal arteries

CRRT

CRRT is a continuous extracorporeal blood purification system managed by the bedside critical care nurse. It is similar to conventional intermittent hemodialysis in that a hemofilter is used to facilitate the processes of ultrafiltration and diffusion. It differs in that CRRT provides a slow removal of solutes and water as compared to the rapid removal of water and solutes that occurs with intermittent hemodialysis. Used with patients too unstable for hemodialysis Advantages More gradual solute removal Flexible fluid administration Minimal heparin Can be done by staff nurses at the bedside Disadvantages Bed rest One-to-one nursing care

Assessment and Diagnostic Findings: Increased ICP

CT scanning and MRI. Maybe: cerebral angiography, PET, or SPECT. Transcranial Doppler studies provide information about cerebral blood flow. Electrophysiologic monitoring to observe cerebral blood flow indirectly. ***Lumbar puncture is avoided in patients with increased ICP, because the sudden release of pressure in the lumbar area can cause the brain to herniate

Increased Intracranial Pressure and Interventions Factor/Physiology/Interventions/Rationale

Cerebral edema: -Can be caused by contusion, tumor, or abscess; water intoxication -Administer osmotic diuretics -HOB elevate30 degrees. -Maintain alignment of the head. -Promotes venous return:Prevents impairment of venous return through the jugular veins Hypoxia -A decrease in PaO2 to <60 mm Hg causes cerebral vasodilation. -Maintain PaO2 >60 mm Hg. -Maintain oxygen therapy. -Monitor arterial blood gas values. -Suction when needed. -Maintain a patent airway. -Prevents hypoxia and vasodilation Hypercapnia (elevated PaCO2) -Causes vasodilation -Maintain PaCO2 (normally 35-45 mm Hg) by establishing ventilation. -Normalizing PaCO2 minimizes vasodilation and thus reduces the cerebral blood volume. Impaired venous return -Increases the cerebral blood volume -Maintain head alignment. -Elevate head of bed 30 degrees. -Hyperextension, rotation, or hyperflexion of the neck causes decreased venous return. Increase in intrathoracic or abdominal pressure -An increase in these pressures due to coughing, PEEP, or Valsalva maneuver causes a decrease in venous return. -Monitor arterial blood gas values, and keep PEEP as low as possible. -Provide humidified oxygen. -Administer stool softeners as prescribed. -To keep secretions loose and easy to suction or expectorate -Soft bowel movements will prevent straining or Valsalva maneuver.

Causes of seizures

Cerebrovascular disease Hypoxemia of any cause, including vascular insufficiency Fever (childhood) Head injury Hypertension CNS infections Metabolic and toxic conditions (e.g., kidney injury, hyponatremia, hypocalcemia, hypoglycemia, pesticide exposure) Brain tumor Drug and alcohol withdrawal Allergies

Tension type headache

Characterized by a steady, constant feeling of pressure that usually begins in the forehead, temple, or back of the neck. It is often band-like or may be described as "a weight on top of my head." Tension-type headaches tend to be chronic and less severe and are probably the most common type of headache.

neurogenic shock

Circulatory failure caused by paralysis of the nerves that control the size of the blood vessels, leading to widespread dilation; seen in patients with spinal cord injuries.

Classifications AKI

Classification criteria for AKI include assessment of three grades of severity and two outcome-level classifications. This 5-point system is known as the RIFLE classification system (RIFLE stands for risk, injury, failure, loss, and ESKD) Risk, injury, and failure are considered grades of AKI severity, whereas loss and ESKD are considered outcomes of loss that require some form of renal replacement therapy, at least temporarily

AKI S/S and Diagnostic Findings

Clinical Manifestations-may appear critically ill and lethargic; dry skin and mucous membranes; dehydrated, CNS: drowsiness, headache, muscle twitching, and seizures Vital signs may be altered Blood pressure changes, depending on etiology Hyperventilation to compensate for metabolic acidosis Body temperature may be altered Assess for volume depletion and volume overload Patients with kidney injury from prerenal causes may be hypotensive and tachycardic as a result of volume deficits. ATN, particularly if associated with oliguria, often causes hypertension. Patients may hyperventilate as the lungs attempt to compensate for the metabolic acidosis often seen in AKI. Body temperature may be decreased (as a result of the antipyretic effect of the uremic toxins), normal, or increased (as a result of infection).

ESRD integumentary symptoms

Coarse, thinning hair Dry, flaky skin Ecchymosis Gray-bronze skin color Pruritus Purpura Thin, brittle nails

Pathophysiology ICP

Common: head injury Secondary effect: brain tumors, subarachnoid hemorrhage, and toxic and viral encephalopathies. Increased ICP from any cause decreases cerebral perfusion, stimulates further swelling (edema), and may shift brain tissue, resulting in herniation—a dire and frequently fatal event. Reduce cerebral blood flow, resulting in ischemia and cell death. In the early stages ischemia: slow bounding pulse and respiratory irregularities. These changes in blood pressure, pulse, and respiration are important clinically because they suggest increased ICP. Increase in (PaCO2) causes cerebral vasodilation, leading to increased cerebral blood flow and increased ICP. A decrease in PaCO2 has a vasoconstrictive effect, limiting blood flow to the brain. Decreased venous outflow may also increase cerebral blood volume, thus raising ICP.

AKI Diuretic Therapy

Controversial Convert oliguria to nonoliguric state Hypovolemia corrected first Loop (furosemide) Osmotic (mannitol) Diuretic therapy in the treatment of patients with AKI is controversial. In clinical practice, diuretics may be used to manage volume overload. Although it is believed that diuretics increase renal blood flow and GFR (thereby increasing urine output), and reduce tubular dysfunction and obstruction, evidence suggests that they may cause excess diuresis and renal hypoperfusion, compromising an already insulted renal system. Diuretics may increase the risk of AKI from volume depletion when they are given before procedures requiring radiological contrast agents or if the patient is hypovolemic. Adequate hydration prior to administration of diuretics is essential.

ESRD Pulmonary Symptoms

Crackles Depressed cough reflex Kussmaul-type respirations Pleuritic pain Shortness of breath Tachypnea Thick, tenacious sputum Uremic pneumonitis

Arteriovenous grafts

Created by using different types of prosthetic material, most commonly polytetrafluoroethylene and Teflon. Grafts are placed under the skin and are surgically anastomosed between an artery (usually brachial) and a vein (usually antecubital). The graft site usually heals within 2 to 4 weeks.

Cushing's Triad

Decompostion Bradycardia Hypertension Bradypnea Grave sign. Herniation of the brainstem and occlusion of the cerebral blood flow occur if therapeutic intervention is not initiated. Herniation refers to the shifting of brain tissue from an area of high pressure to an area of lower pressure The herniated tissue exerts pressure on the brain area into which it has shifted, which interferes with the blood supply in that area. Cessation of cerebral blood flow results in cerebral ischemia, infarction, and brain death.

phosphate binders AKI

Decreased renal excretion of phosphate is the primary cause of hyperphosphatemia in most patients with AKI. In addition, phosphate may be released into the circulation from intracellular stores under conditions of massive tissue breakdown (eg, tumor lysis syndrome and rhabdomyolysis) Phosphate binders are used to reduce positive phosphate balance and to lower serum phosphate levels for people with chronic kidney disease (CKD) with the aim to prevent progression of chronic kidney disease-mineral and bone disorder (CKD-MBD).

Assessment and Diagnostic Findings: Seizures

Determining the type of seizures, their frequency and severity, and the factors that precipitate them. Take hx: events of pregnancy and childbirth, to seek evidence of pre-existing injury; illnesses or head injuries that may have affected the brain. -Physical and neuro evals -Diagnostic examinations: biochemical, hematologic, and serologic studies -MRI is used to detect structural lesions such as focal abnormalities, cerebrovascular abnormalities, and cerebral degenerative changes -EEG: evidence for a substantial proportion of patients with epilepsy and assists in classifying the type of seizure; abnormalities usually continue between seizures or, if not apparent, may be elicited by hyperventilation or during sleep Microelectrodes (depth electrodes): can be inserted deep in the brain to probe the action of single brain cells. Some people with clinical seizures have normal EEGs, whereas others who have never had seizures have abnormal EEGs. Telemetry and computerized equipment are used to monitor electrical brain activity while the patient pursues their normal activities and to store the readings on computer tapes for analysis. -Video recording of seizures taken simultaneously with EEG telemetry is useful in determining the type of seizure as well as its duration and magnitude SPECT sometimes used; identifies the epileptogenic zone so that the area in the brain giving rise to seizures can be removed surgically

AKI Drug Therapy

Dopamine May increase renal blood flow Efficacy questioned in current research Acetylcysteine (Mucomyst IV) Prevent contrast-induced AKI Epoetin alfa Treat anemia Must adjust dosages and timing of medication if patient is on dialysis Dopamine administration remains controversial. Several drugs are being evaluated for their role in preventing contrast-induced AKI. Epoetin is given to treat anemia associated with decreased erythropoetin production.

Glascow Coma Scale

EYE OPENING 4 - spontaneous 3 - open to speech 2 - open to pain 1 - no response VERBAL 5 - alert and oriented 4 - disoriented conversation 3 - inappropriate words 2 - nonsensical sounds 1 - no response MOTOR 6 - spontaneous 5 - localizes pain 4 - withdraws to pain 3 - decorticate posturing 2 - decerebrate posturing 1 - no movement The Glasgow Coma Scale is a tool for assessing a patient's response to stimuli. Scores range from 3 (deep coma) to 15 (normal).

Prerenal Medical Management AKI

Early recognition Fluid or volume replacement Caution in patients with underlying cardiac disease May require inotropes, antidysrhythmic agents, preload/afterload reducers, intraaortic balloon pump May require hemodynamic monitoring to guide treatment AKI from prerenal conditions is usually reversible if renal perfusion is quickly restored; therefore, early recognition and prompt treatment are essential. Treatments include fluids and inotropes.

Seizure Pathophysiology

Electrical disturbance (dysrhythmia) in the nerve cells in one section of the brain; these cells emit abnormal, recurring, uncontrolled electrical discharges. -Characterized by excessive neuronal discharge. -Associated loss of consciousness, excess movement or loss of muscle tone or movement, and disturbances of behavior, mood, sensation, and perception may also occur. The specific causes of seizures are varied and can be categorized as genetic, due to a structural or metabolic condition, or the cause may be yet unknown etiologies

Controlling ICP in Patients With Severe Brain Injury

Elevate the head of the bed as prescribed. Maintain the patient's head and neck in neutral alignment (no twisting or flexing the neck). Initiate measures to prevent the Valsalva maneuver (e.g., stool softeners). Maintain body temperature within normal limits. Administer oxygen (O2) to maintain partial pressure of arterial oxygen (PaO2) >90 mm Hg. Maintain fluid balance with normal saline solution. Avoid noxious stimuli (e.g., excessive suctioning, painful procedures). Administer sedation to reduce agitation. Maintain cerebral perfusion pressure of 50-70 mm Hg.

Seizure Disorders

Episodes of abnormal motor, sensory, autonomic, or psychic activity (or a combination of these) that result from sudden excessive discharge from cerebral neurons -A localized area or all of the brain may be involved. -Epilepsy as at least two unprovoked seizures occurring more than 24 hours apart Three main seizure types: 1)focal 2)generalized 3)unknown seizures 1)Generalized seizures- occur in and rapidly engage bilaterally distributed networks. 2)Focal seizures-thought to originate within one hemisphere in the brain. 3)Unknown type includes epileptic spasms. Unclassified seizures are so termed because of incomplete data but are not considered a classification Seizures may also be characterized as "provoked," or related to acute, reversible conditions such as structural, metabolic, immune, infectious or unknown etiologies

Ergotamine

Ergotamine preparations (taken orally, sublingually, subcutaneously, intramuscularly, by rectum, or by inhalation) May be effective in aborting the headache if taken early in the migraine process. Low in cost. Acts on smooth muscle, causing prolonged constriction of the cranial blood vessels. Dosage is based on individual needs. Side effects: aching muscles, paresthesias (numbness and tingling), nausea, and vomiting. Pretreatment with antiemetic agents may be required. None of the triptan medications should be taken concurrently with medications containing ergotamine because of the potential for a prolonged vasoactive reaction

BUN-to-creatinine ratio

Evaluates hydration status. An elevated ratio is seen in hypovolemia; a normal ratio with an elevated BUN and creatinine is seen with intrinsic kidney disease. About 10:1

Communicating With the Patient With Aphasia

Face the patient and establish eye contact. Speak in a clear, unhurried manner, and normal tone of voice. Use short phrases, and pause between phrases to allow the patient time to understand what is being said. Limit conversation to practical and concrete matters. Use gestures, pictures, objects, and writing. As the patient uses and handles an object, say what the object is. It helps to match the words with the object or action. Be consistent in using the same words and gestures each time you give instructions or ask a question. Keep extraneous noises and sounds to a minimum. Too much background noise can distract the patient or make it difficult to sort out the message being spoken.

AKI Patho

Factors: identify and treat promptly, before kidney function is impaired. Conditions that affect blood flow to the kidney and impair kidney function: (1) hypovolemia (2) hypotension (3) reduced cardiac output and heart failure (4) obstruction of the kidney or lower urinary tract by tumor, blood clot, or kidney stone (5) bilateral obstruction of the renal arteries or veins. S/S: If these conditions are treated and corrected before the kidneys are permanently damaged, the increased BUN and creatinine levels, oliguria, and other signs may be reversed.

PD benefits

Fewer negative side effects (such as nausea, vomiting, cramping, and weight gain) than with hemodialysis Provides continuous therapy, which acts more like natural kidneys Can allow for fewer dietary restrictions Needle-free treatments Direct shipment of PD supplies to your home or travel destination Do not have to travel to the dialysis center for treatments Greater flexibility and freedom in your treatment schedule Can do dialysis while sleeping Allows for travel

Medical Management: Status Epilepticus

Goal of tx: to stop the seizures as quickly as possible, to ensure adequate cerebral oxygenation, and to maintain the patient in a seizure-free state. -Establish Airway and Oxygenation - If unconscious/unresponsive: insert endotracheal tube -Establish IV: IV diazepam (Valium), lorazepam (Ativan), or fosphenytoin is given slowly in an attempt to halt seizures immediately. -Other medications (phenytoin, phenobarbital) are given later to maintain a seizure-free state. -Blood samples are obtained to monitor serum electrolytes, glucose, and phenytoin levels. -EEG: determine the nature of the seizure activity. -Monitor Vital signs and neurologic signs continuously Hypoglycemia: An IV infusion of dextrose Still unstable: general anesthesia with a short-acting barbiturate may be used. -The serum concentration of the anticonvulsant medication is measured; low level suggests that the patient was not taking the medication or that the dosage was too low. -Cardiac involvement or respiratory depression may be life threatening. The potential for postictal cerebral edema also exists.

Epilepsy

Group of syndromes characterized by unprovoked, recurring seizures Classified by specific patterns of clinical features, including age at onset, family history, and seizure type. Can be primary (idiopathic) or secondary (when the cause is known and the epilepsy is a symptom of another underlying condition, such as a brain tumor). May be inherited, but the cause in many is idiopathic (unknown). -Epilepsy can follow birth trauma, asphyxia neonatorum, head injuries, some infectious diseases (bacterial, viral, parasitic), toxicity (carbon monoxide and lead poisoning), circulatory problems, fever, metabolic and nutritional disorders, or drug or alcohol intoxication. It is also associated with brain tumors, abscesses, and congenital malformations. Not associated with intellectual level But many w/ neuro disabilities, b/c of serious neurologic damage, also have epilepsy.

Signs and Symptoms of a Stroke

Happens suddenly: need to act fast as the nurse to help save brain cells call rapid response so patient can receive appropriate treatment or call 911 (if outside of the hospital in the United States) NOTE the exact time the signs and symptoms appears...important for stroke treatment "FAST" Face: drooping or uneven smile Arm: numbness, weakness, drift (raise both arms) Speech: can't repeat a phrase, slurred speech Time: to call rapid response and note the time **National Stroke Association recommends using the mnemonic F.A.S.T. to help assess for signs and symptoms quickly. The patient can also have the following as well: Bowel and bladder incontinence or retention

Prevent headache

Having the patient avoid specific triggers that are known to initiate the headache syndrome. The daily use of one or more agents that are thought to block the physiologic events leading to an attack. Treatment regimens vary greatly, as do patient responses Close monitoring is indicated. Alcohol, nitrites, vasodilators, and histamines may precipitate cluster headaches. Elimination of these factors helps prevent the headaches

Fluid and Electrolyte Imbalances

Hyperkalemia Low excretion Hyponatremia Fluid retention Hypocalcemia Low excretion of phosphorus Decreased level of vitamin D Hyperphosphatemia Low excretion Hypermagnesemia Low excretion

Hyperkalemia w/ AKI

Hyperkalemia is common in acute kidney injury, especially if the patient is hypercatabolic. Hyperkalemia occurs when potassium excretion is reduced as a result of the decrease in GFR. Sudden changes in the serum potassium level can cause dysrhythmias, which may be fatal. Alterations in sodium, calcium, phosphorus, and magnesium may also be noted.

Hyponatremia AKI

Hyponatremia generally occurs from water overload. As nephrons are progressively damaged, the ability to conserve sodium is lost, and major salt-wasting states can develop, causing hyponatremia. Hyponatremia is treated with fluid restriction, specifically restriction of free water intake.

Invasive tests AKI

IV pyelogram Computed tomography Structures, accumulation of fluid Renal angiography Abnormalities in blood flow; infarction; masses Renal scan Renal uptake of isotopes Renal biopsy Histological changes

B.M. Dx tests

Identify the causative organism. (CT) scan: detect a shift in brain contents (which may lead to herniation) prior to a lumbar puncture in patient with altered LOC, papilledema, neurologic deficits, new onset of seizure, immunocompromised state, or history of central nervous system (CNS) disease. Bacterial culture and Gram staining of CSF and blood are key diagnostic tests Gram staining allows for rapid identification of the causative bacteria and initiation of appropriate antibiotic therapy

Headache Diagnostic Testing

In patients who demonstrate abnormalities on the neurologic examination, CT scan, cerebral angiography, or MRI scan may be used to detect underlying causes, such as tumor or aneurysm. Electromyography (EMG) may reveal a sustained contraction of the neck, scalp, or facial muscles. Laboratory tests may include complete blood count, erythrocyte sedimentation rate, electrolytes, glucose, creatinine, and thyroid hormone levels.

Bacterial meningitis to ICP

Initial signs of increased ICP: -decreased level of consciousness (LOC) -focal motor deficits. Uncus of the temporal lobe may herniate through the tentorium, causing pressure on the brainstem. Brainstem herniation is a life-threatening Causes cranial nerve dysfunction and depresses the centers of vital functions, such as the medulla. Signs of sepsis: an abrupt onset of high fever, extensive purpuric lesions (over the face and extremities), shock, and signs of disseminated intravascular coagulation; Death may occur within a few hours after onset of the infection.

B.M. Clinical manifestations

Initial: Headache:steady or throbbing and very severe as a result of meningeal irritation Fever: tends to remain high throughout Common 1)Nuchal Rigidity 2)Positive Kernig sign 3)Positive Brudzinski sign 4)Photophobia (extreme sensitivity to light): This finding is common due to irritation of the meninges, especially around the diaphragm sellae 5)A rash (N. meningitidis): Skin lesions develop, ranging from a petechial rash with purpuric lesions to large areas of ecchymosis. 6)Disorientation and memory impairment (early) Behavioral manifestations: illness progresses, lethargy, unresponsiveness, and coma may develop. -Seizures can occur and are the result of areas of irritability in the brain. ICP increases secondary to diffuse brain swelling or hydrocephalus

How is Kayexalate given? What is the expected effect of administration?

Kayexalate reduces plasma potassium levels and total body potassium content in a patient with renal dysfunction. In the past, sorbitol has been combined with sodium polystyrene sulfonate powder (Kayexalate) for administration. The concomitant use of sorbitol with Kayexalate has been implicated in cases of colonic intestinal necrosis and thus this combination is not recommended. Other treatments only "protect" the patient for a short time until dialysis or cation exchange resins can be instituted.

Later Signs and Symptoms of Increasing ICP

LOC continues to deteriorate until the patient is comatose (Glasgow Coma Scale score ≤8). The pulse rate and respiratory rate decrease or become erratic, and the blood pressure and temperature increase. The pulse pressure widens. The pulse fluctuates rapidly, varying from bradycardia to tachycardia. Altered respiratory patterns develop, including Cheyne-Stokes breathing and ataxic breathing (irregular breathing with a random sequence of deep and shallow breaths). Projectile vomiting may occur with increased pressure on the reflex center in the medulla. Hemiplegia or decorticate or decerebrate posturing may develop as pressure on the brainstem increases; bilateral flaccidity occurs before death. Loss of brainstem reflexes, including pupillary, corneal, gag, and swallowing reflexes, is an ominous sign of approaching death.

Dopamine Meds

Levodopa Carbidopa Dopamine at low doses augments renal blood flow by its action predominantly on the dopamine-1 receptors on the renal vasculature causing vasodilatation. In intermediate doses it acts on the ß-adrenergic receptors and increases renal blood flow by increasing the cardiac output. Oliguria is the most prevalent sign of acute kidney injury. Low dose dopamine (1 - 3 µg/kg/min), due to its effects on dopaminergic receptors of the kidneys, is usually used to dilate the renal arteries and increase the urine output.

Renal Replacement Therapy (RRT)

Lifesaving treatment Classification Hemodialysis Continuous renal replacement therapy (CRRT) Peritoneal dialysis Renal replacement therapy is the primary treatment for the patient with AKI. The decision to initiate renal replacement therapy is a clinical decision based on the fluid, electrolyte, and metabolic status of an individual patient. Renal replacement therapy options include intermittent hemodialysis, continuous renal replacement therapy (CRRT), and peritoneal dialysis.

AKI Medical Management

Management includes eliminating the underlying cause; maintaining fluid balance; avoiding fluid excesses; and, when indicated, providing renal replacement therapy. Shock and infection, if present, are treated promptly The presence of myoglobin in the urine (i.e., myoglobinuria) in the patient who has had a crush injury, compartment syndrome, or heat-induced illness is treated for rhabdomyolysis

Aura Phase

May be a variable feature for patients who experience migraines Characteristized by focal neurologic symptoms. Visual disturbances (i.e., light flashes and bright spots) are most common and may be hemianopic (affecting only half of the visual field). Other symptoms that may follow include numbness and tingling of the lips, face, or hands; mild confusion; slight weakness of an extremity; drowsiness; and dizziness. This period of aura was thought to correspond to the phenomenon of cortical spreading depression that is associated with reduced metabolic demand in abnormally functioning neurons. This can be associated with decreased blood flow; however, cerebral blood flow studies performed during migraine headaches demonstrate that although changes in blood vessels occur during phases of migraine, cerebral blood flow is not the main abnormality. Some studies suggest that the aura and headache phases may occur simultaneously

Electrolyte Imbalances from ARF

May lead to dysrhythmias, such as ventricular tachycardia and cardiac arrest. Sources of potassium: normal tissue catabolism, dietary intake, blood in the GI tract, or blood transfusion and other sources (e.g., IV infusions, potassium penicillin, and extracellular shift in response to metabolic acidosis). -Progressive metabolic acidosis occurs in kidney disease because patients cannot eliminate the daily metabolic load of acid-type substances produced by the normal metabolic processes. -Normal renal buffering mechanisms fail. This is reflected by decreased serum carbon dioxide (CO2) and pH levels. -Blood phosphate concentrations may increase; calcium levels may be low due to decreased absorption of calcium from the intestine and as a compensatory mechanism for the elevated blood phosphate levels. -Anemia is another common laboratory finding in AKI, as a result of reduced erythropoietin production, uremic GI lesions, reduced RBC lifespan, and blood loss from the GI tract.

Creatine level

Measures effectiveness of renal function. Creatinine is the end product of muscle energy metabolism. In normal function, the level of creatinine, which is regulated and excreted by the kidneys, remains fairly constant in the body. 0.6-1.2 mg/dL (50-110 mmol/L)

Metabolic acidosis AKI

Metabolic acidosis is the primary acid-base imbalance seen in AKI. Treatment of metabolic acidosis depends on its severity. May need IV bicarbonate Monitor ionized calcium as hypocalcemia can occur as pH is corrected

Headache Phase

Migraine headache is severe and incapacitating and is often associated with photophobia (light sensitivity), phonophobia (sound sensitivity), or allodynia (abnormal perception of innocuous stimuli) Research differs in the role of vascular changes (either vasodilatory or vasoconstrictive) with respect to migraine pathophysiology and the experience of migraine headache. Symptoms of migraine can also include nausea and vomiting.

Acetylcysteine

Mucolytic N-Acetylcysteine (NAC) has been reported to protect the kidney from injury induced by contrast media, ischemia, and toxins. In all these studies, glomerular filtration rate (GFR) is the surrogate marker of kidney injury and serum creatinine changes are the measured metric of GFR.

The disadvantages of PD include:

Must schedule dialysis into your daily routine, seven days a week Requires a permanent catheter, outside the body Runs the risk of infection/peritonitis May gain weight/have a larger waistline Very large people may need extra therapy Need ample storage space in your home for supplies Need space in your bedroom for equipment and PD machine Requires responsibility and detailed training

nuchal rigidity

Neck immobility: A stiff and painful neck (nuchal rigidity) can be an early sign, and any attempts at flexion of the head are difficult because of spasms in the muscles of the neck. Usually, the neck is supple, and the patient can easily bend the head and neck forward.

Diagnostic Studies

Noninvasive diagnostic procedures that assess the renal system are radiography of the kidneys, ureters, and bladder (KUB); renal ultrasonography; and magnetic resonance imaging. KUB x-ray: delineates the size, shape, and position of the kidneys. It may also detect abnormalities such as calculi, hydronephrosis (dilatation of the renal pelvis), cysts, or tumors. Renal ultrasound is helpful in evaluating for obstruction, which is manifest by hydronephrosis or hydroureter (dilatation of the ureters). Ultrasound can also document the size of the kidneys, which may be helpful in differentiating acute from chronic renal conditions. The kidneys are often small (<10 cm) in chronic kidney disease. Real-time ultrasound is used during renal biopsy and during placement of percutaneous nephrostomy tubes (often placed for hydronephrosis). Magnetic resonance imaging (MRI) provides anatomic information about renal structures.

Nursing Care during Seizure

Observe and record the sequence of signs: -Circumstances before the seizure (visual, auditory, or olfactory stimuli; tactile stimuli; emotional or psychological disturbances; sleep; hyperventilation) -Occurrence of an aura (a premonitory or warning sensation, which can be visual, auditory, or olfactory) -Where the movements or the stiffness begins, conjugate gaze position, and the position of the head at the beginning of the seizure. This info gives clues to origin in the brain -Type of movements in the part of the body involved Areas of the body involved (turn back bedding to expose patient) -Size of both pupils and whether the eyes are open Whether the eyes or head are turned to one side -Presence or absence of automatisms (involuntary motor activity, such as lip smacking or repeated swallowing) -Incontinence of urine or stool -Duration of each phase of the seizure -Unconsciousness, if present, and its duration -Any obvious paralysis or weakness of arms or legs after the seizure -Inability to speak after the seizure -Movements at the end of the seizure -Whether or not the patient sleeps afterward -Cognitive status (confused or not confused) after the seizure -Prevent injury and support the patient (anxiety, embarrassment, fatigue, and depression)

Generalized Seizures s/s

Often involve both hemispheres of the brain, causing both sides of the body to react. -Intense rigidity of the entire body may occur, followed by alternating muscle relaxation and contraction (generalized tonic-clonic contraction). -The simultaneous contractions of the diaphragm and chest muscles may produce a characteristic epileptic cry. The tongue is often chewed, and the patient is incontinent of urine and feces. Convulsive movements subside after 1 or 2 minutes, Pt. relaxes and lies in deep coma, breathing noisily; abdominal respirations -Postictal state (after the seizure): confused and hard to arouse and may sleep for hours; report headache, sore muscles, fatigue, and depression

Epilepsy in Elderly

Older adults have a high incidence of new-onset epilepsy -Cerebrovascular disease is the leading cause of seizures in the older adult. -The increased incidence with head injury, dementia, infection, alcoholism, and aging. Treatment depends on the underlying cause. Chronic health problems= medications that can interact with medications prescribed for seizure control. Absorption, distribution, metabolism, and excretion of medications are altered in the older adult as a result of age-related changes in renal and liver function Monitor closely for adverse and toxic effects of anticonvulsant medications and for osteoporosis. The cost of anticonvulsant medications can lead to poor adherence to the prescribed regimen in older adult patients on fixed incomes.

Mannitol

Osmotic diuretic used to treat increased intracranial pressure Mannitol, an osmotic diuretic, is commonly used to treat patients with acute brain edema, but its use also increases the risk of developing acute kidney injury (AKI). In this study, we investigated the incidence and risk factors of mannitol-related AKI in acute stroke patients Mannitol therapy should be discontinued if progression in renal damage or dysfunction, heart failure, or pulmonary congestion occurs. A test dose should be administered in patients with severe renal impairment. Diuresis caused by mannitol administration may exacerbate electrolyte imbalances

SCI Nursing Intervention

PROMOTING ADEQUATE BREATHING AND AIRWAY CLEARANCE IMPROVING MOBILITY -Proper body alignment is maintained at all times -Do not turn until cleared by HCP -Once safe, reposition frequently and is assisted out of bed as soon as the spinal column is stabilized. -Foot Splints are removed and reapplied Q2 -Trochanter rolls: help prevent external rotation of the hip joints. Contractures/atrophy: ROM exercises that help preserve joint motion and stimulate circulation. Passive range-of-motion exercises should be implemented ASAP Cervical fracture: A neck brace or molded collar is applied when the patient is mobilized after traction is remove PREVENTING INJURY DUE TO SENSORY AND PERCEPTUAL ALTERATIONS Providing glasses Encouraging the use of hearing aid Providing emotional support Educating MAINTAINING SKIN INTEGRITY Pressure ulcer: position is changed at least every 2 hours Careful inspection of the skin is made each time the patient is turned Wash with a mild soap, rinsing well, and blotting dry. MAINTAINING URINARY ELIMINATION Urinary retention= intermittent catheterization Record I/O's IMPROVING BOWEL FUNCTION Paralytic ileus= NG tube Bowel activity usually returns within the first week. Bowel program: stool softeners, stimulant laxatives, bulking laxatives, and rectal laxatives along with rectal stimulation, to counteract the effects of immobility and analgesic agents

Categories of AKI

Prerenal (hypoperfusion of kidney) Intrarenal (actual damage to kidney tissue) Postrenal (obstruction to urine flow).

Clinical manifestations: Seizures

Range from a simple staring episode (generalized absence seizure) to prolonged convulsive movements with loss of consciousness. The initial pattern of the seizures indicates the region of the brain in which the seizure originates S/S: Only a finger or hand may shake, or the mouth may jerk uncontrollably. The person may talk unintelligibly; may be dizzy; and may experience unusual or unpleasant sights, sounds, odors, or tastes, but without loss of consciousness

Migraine Patient education

Recognize triggers of migraine headaches and how to avoid such triggers as: -Foods that contain tyramine, such as chocolate, cheese, coffee, dairy products (and MOAI's) -Dietary habits that result in long periods between meals -Menstruation and ovulation (caused by hormone fluctuation) -Alcohol (causes vasodilation of blood vessels) -Fatigue and fluctuations in sleep patterns Develop headache diary. Implement stress management and lifestyle changes to minimize the frequency of headaches. Ensure correct pharmacologic management: acute therapy and prophylaxis to include medication regimen and side effects. Use comfort measures during headache attacks, such as resting in a quiet and dark environment, applying cold compresses to the painful area, and elevating the head. Seek out resources for education and support, such as the National Headache Foundation.

ESRD other symptoms

Reproductive Amenorrhea Decreased libido Infertility Testicular atrophy Musculoskeletal Bone fractures Bone pain Footdrop Loss of muscle strength Muscle cramps Renal osteodystrophy

AKI Lab Tests

Serum creatinine Serum BUN Affected by catabolism, bleeding, and dehydration BUN:creatinine ratio Normal 10:1 to 20:1 More than 20:1, suspect nonrenal causes of laboratory abnormalities BUN and creatinine levels assist in diagnosis. The creatinine is more specific to kidney injury. The ratio is also evaluated. Urine creatinine clearance Estimate of GFR 24-hour urine; specific collection protocol Normal 84 to 138 mL/min Can calculate an estimated value with serum lab values (Cockcroft and Gault formula) Urine creatinine clearance provides an estimate of GFR. In the absence of a 24-hour collection, GFR is estimated using standard formulas.

BUN level

Serves as index of renal function. Urea is the nitrogenous end product of protein metabolism. Test values are affected by protein intake, tissue breakdown, and fluid volume changes. 7-18 mg/dL; patients >60 years: 8-20 mg/dL

Vitamins for AKI

Special renal vitamins are usually prescribed to provide extra water soluble vitamins needed. Renal vitamins contain vitamins B1, B2, B6, B12, folic acid, niacin, pantothenic acid, biotin and a small dose of vitamin C.

Focal Seizures s/s

Subdivided into events characterized by both motor and non-motor symptoms. There may be an impairment of consciousness or awareness or other dyscognitive features, localization, and progression of symptoms

Medical Management: Bacterial Meningitis

Success: early administration of an antibiotic agent that crosses the blood-brain barrier into the subarachnoid space in sufficient concentration to halt the multiplication of bacteria. Penicillin G in combination with one of the cephalosporins (e.g., ceftriaxone sodium, cefotaxime sodium) is most often administered intravenously (IV), optimally within 30 minutes of hospital arrival -Dexamethasone: adjunct therapy in the treatment of acute bacterial meningitis and in pneumococcal meningitis if it is given 15 to 20 minutes before the first dose of antibiotic and every 6 hours for the next 4 days. -Dexamethasone improves the outcome in adults and does not increase the risk of gastrointestinal bleeding

Can the dialysis catheter be used to draw blood samples or give medications?

The extremity that has a fistula or graft must never be used for drawing blood specimens, obtaining blood pressure measurements, intravenous therapy, or intramuscular injections. Such activities produce pressure changes within the altered vessels that could result in clotting or rupture.

What are appropriate interventions if the patient has a graft or shunt?

The nurse must alert other health care personnel of the presence of the fistula or graft by posting a large sign at the head of the patient's bed that indicates which arm should be used.

What are important nursing interventions for the patient with a percutaneous dialysis catheter?

The nurse must protect the vascular access site. An arteriovenous fistula or graft should be auscultated for a bruit and palpated for the presence of a thrill or buzz every 8 hours.

AKI Urine tests

The nurse obtains urine samples (often called spot urine levels) for electrolyte determinations before diuretics are administered because these drugs alter the urine results for up to 24 hours. Urinary sodium concentrations of less than 10 mEq/L are seen in prerenal conditions, as the kidneys attempt to conserve sodium and water to compensate for the hypoperfusion state. Urine sodium concentrations are greater than 40 mEq/L in ATN as a result of impaired reabsorption in the diseased tubules. Urine specific gravity and osmolality have a limited role in the diagnosis of acute kidney injury, especially in older adults, because the body's ability to concentrate urine decreases with age. In general, prerenal conditions cause concentrated urine (high specific gravity and osmolality), whereas intrinsic azotemia causes dilute urine (low specific gravity and osmolality).

Postdrome Phase

The pain gradually subsides, but patients may experience tiredness, weakness, cognitive difficulties, and mood changes for hours to days. Muscle contraction in the neck and scalp is common, with associated muscle ache and localized tenderness. Physical exertion may exacerbate the headache pain. During this postheadache phase, patients may sleep for extended periods.

Medical Management: Migraines

The triptans, which are serotonin receptor agonists, are the most specific antimigraine agents available. Example: sumatriptan (Imitrex) Numerous serotonin receptor agonists are under study. Many of the triptan medications are available in a variety of formulations, such as nasal sprays, inhalers, conventional tablet, disintegrating tablet, suppositories, or injections. The nasal sprays are useful for patients experiencing nausea and vomiting The triptans are considered first-line treatment of the management of moderate to severe migraine pain.

CRRT Types

There are four types of continuous venous-to-venous replacement therapies: 1. Slow continuous ultrafiltration (SCUF) 2. Continuous venovenous hemofiltration (CVVH) 3. Continuous venonvenous hemodialysis (CVVHD) 4. Continuous venovenous hemodiafiltration (CVVHDF)

Hemodialysis

Usually done at the bedside in the ICU Pre- and postdialysis labs and weight Monitor for complications Volume depletion Dysrhythmias Hypoxemia Disequilibrium syndrome Vascular access infections Hemodialysis consists of simply cleansing the patient's blood through a hemofilter by the use of diffusion and ultrafiltration. Water and waste products of metabolism are easily removed. Hemodialysis is efficient and corrects biochemical disturbances quickly. Treatments are typically 3 to 4 hours long and are performed in the critical care unit at the patient's bedside. Patients with AKI may be hemodynamically unstable and unable to tolerate intermittent hemodialysis.

CSF leak

When a CSF leak occurs, it may cause any or all of the following symptoms: headache nasal drainage meningitis visual disturbances tinnitus Drainage from ear or nose (halo effect on tissues or sheets) Direct opening into subarachnoid space Check drainage for glucose (drip into a sterile container and check) Antibiotics (because they have injury) To determine the exact location of the leak, a CT cisternogram would be performed. A CT cisternogram involves using a contrast injected into the spinal fluid through a spinal tap and then performing CT scans. This test identifies the exact location of the CSF leak and the pathway of the drainage into the nose.

Positive Kernig sign

When the patient is lying with the thigh flexed on the abdomen, the leg cannot be completely extended When Kernig sign is bilateral, meningeal irritation is suspected Flex the patient's leg at both the hip and knee and then straighten the knee.

Positive Brudzinski sign:

When the patient's neck is flexed (after ruling out cervical trauma or injury), flexion of the knees and hips is produced; when the lower extremity of one side is passively flexed, a similar movement is seen in the opposite extremity Brudzinski sign is a more sensitive indicator of meningeal irritation than Kernig sign. As the neck is flexed, watch the hips and knees for a reaction.

Medical Mangement: Azotemia

abnormal concentration of nitrogenous waste products in the blood Prerenal azotemia:optimizing renal perfusion, Postrenal failure is treated by relieving the obstruction. Intrarenal azotemia: treated with supportive therapy, with removal of causative agents, aggressive management of prerenal and postrenal failure, and avoidance of associated risk factors.

Status Epilepticus

acute prolonged seizure activity Series of generalized seizures that occur without full recovery of consciousness between attacks Include continuous clinical or electrical seizures (on EEG) lasting at least 30 minutes, even without impairment of consciousness Considered a medical emergency Cumulative effects: -Vigorous muscular contractions impose a heavy metabolic demand and can interfere with respirations -Some respiratory arrest at the height of each seizure produces venous congestion and hypoxia of the brain. -Repeated episodes of cerebral anoxia and edema may lead to irreversible and fatal brain damage. Precipitating factors: interruption of anticonvulsant medication, fever, concurrent infection, or other illness.

SDH

subdural hematoma Collection of blood between the dura and the brain, a space normally occupied by a thin cushion of fluid. The most common cause is trauma, but it can also occur as a result of coagulopathies or rupture of an aneurysm. Frequently venous in origin and is caused by the rupture of small vessels that bridge the subdural space SDHs may be acute or chronic depending on the size of the involved vessel and the amount of bleeding on CT scan.

Central venous catheter

temporary access device

Hemorrhagic Stroke

this occurs when there is bleeding in the brain due to a break in a blood vessel. Therefore, no blood will perfuse to the brain cells. In addition, this can lead to excessive swelling from the leakage of blood in the brain. Causes of this type of stroke includes: rupture of a brain aneurysm, uncontrolled hypertension, or aging blood vessels (older age). Cause: Intracerebral hemorrhage Subarachnoid hemorrhage Cerebral aneurysm Arteriovenous malformation S/S: "Exploding headache" Decreased level of consciousness Recovery: Slower, usually plateaus at about 18 months

TIAs

transient ischemic attacks; numbness, paralysis, impaired speech; red flags for strokes (transient ischemic attack) also called a mini-stroke. This is where signs and symptoms of a stroke occurs but last only a few minutes to hours and resolves. It is a warning signs an impending stroke may occur. If this occurs the patient needs to seek treatment.

Headache assessment questions

What is the location? Is it unilateral or bilateral? Does it radiate? What is the quality—dull, aching, steady, boring, burning, intermittent, continuous, paroxysmal? How many headaches occur during a given period of time? What are the precipitating factors, if any—environmental (e.g., sunlight, weather change), foods, exertion, other? What makes the headache worse (e.g., coughing, straining)? What time (day or night) does it occur? How long does a typical headache last? Are there any associated symptoms, such as facial pain, lacrimation (excessive tearing), or scotomas (blind spots in the field of vision)? What usually relieves the headache (aspirin, nonsteroidal anti-inflammatory drugs, ergot preparation, food, heat, rest, neck massage)? Does nausea, vomiting, weakness, or numbness in the extremities accompany the headache? Does the headache interfere with daily activities? Do you have any allergies? Do you have insomnia, poor appetite, loss of energy? Is there a family history of headache? What is the relationship of the headache to your lifestyle or physical or emotional stress? What medications are you taking?

Arteriovenous fistula

is an internal, surgically created communication between an artery and a vein. Involves anastomosing the radial artery and cephalic vein in a side-to-side or end-to-side manner. The anastomosis permits blood to bypass the capillaries and flow directly from the artery into the vein. As a result, the vein is forced to dilate to accommodate the increased pressure that accompanies the arterial blood. This method produces a vessel that is easy to cannulate but requires 4 to 6 weeks before it is mature enough to use.

Risk Factors for stroke

"Strokes Happen" Smoking Thinners (blood) Rhythm changes (a-fib/flutter) Oral Contraceptive Kin (family history) Excessive weight Senior citizens Hypertension Atherosclerosis Physical inactivity Previous TIA Elevated blood sugar (diabetes mellitus) aNeurysm (brain)

Ischemic Stroke

(most common): due to a blood clot within a blood vessel or stenosis of an artery that feeds the brain tissue. This limits the blood that can reach the brain cells. This type of stroke can happen due to: Embolism: where a clot has left a part of the body (example the heart: this can happen due to a heart valve problem or atrial fibrillation). The clot develops in the heart and travels to the brain, which stops blood flow. Thrombosis: Clot forms within the artery wall within the neck or brain. This is seen in patients with hyperlipidemia or atherosclerosis Cause: Large artery thrombosis Small penetrating artery thrombosis Cardiogenic embolic Cryptogenic (no known cause) Other S/S: Numbness or weakness of the face, arm, or leg, especially on one side of the body Recovery Usually plateaus at 6 months

Epilepsy in Women

+1 million American women have epilepsy -Women with epilepsy often note an increase in seizure frequency during menses; this has been linked to the increase in sex hormones that alter the excitability of neurons in the cerebral cortex. -The effectiveness of contraceptives is decreased by anticonvulsant medications; discuss family planning with their primary provider and to obtain preconception counseling if they are considering childbearing Special care and guidance before, during, and after pregnancy Change in the pattern of seizure activity during pregnancy Congenital fetal anomaly 2-3X higher in women with epilepsy; Maternal seizures, anticonvulsant medications, and genetic predisposition all contribute to possible malformations. -Mothers who are at high risk (teenagers, women with histories of difficult deliveries, women who use illicit drugs [e.g., "crack" cocaine, heroin], and women with diabetes or hypertension) should be identified and monitored closely during pregnancy, because damage to the fetus during pregnancy and delivery can increase the risk of epilepsy -Bone loss associated with the long-term use of anticonvulsant medications; should be assessed for low bone mass and osteoporosis; preventative education

Prerenal AKI

-60% to 70% of cases, is the result of impaired blood flow that leads to hypoperfusion of the kidney commonly caused by volume depletion (burns, hemorrhage, GI losses), hypotension (sepsis, shock), and renal artery stenosis, ultimately leading to a decrease in the GFR Volume depletion resulting from: -Gastrointestinal losses (vomiting, diarrhea, nasogastric suction) -Hemorrhage -Renal losses (diuretic agents, osmotic diuresis) -Impaired cardiac efficiency resulting Cardiogenic shock -Dysrhythmias -Heart failure -Myocardial infarction -Vasodilation resulting Anaphylaxis: -Antihypertensive medications or other medications that cause vasodilation -Sepsis

Nursing care: After Seizure

-ABC's -Document the events leading to and occurring during and after the seizure and to prevent complications (e.g., aspiration, injury). -At risk for hypoxia, vomiting, and pulmonary aspiration -Place in the side-lying position to facilitate drainage of oral secretions, and suctioning is performed, if needed, to maintain a patent airway and prevent aspiration -Seizure precautions: having available functioning suction equipment with a suction catheter and oral airway; bed is placed in a low position with two to three side rails up and padded, if necessary, to prevent injury to the patient -May be drowsy and may wish to sleep after the seizure; they may not remember events leading up to the seizure and for a short time thereafter.

AKI medical management: Fluids

-Based on daily body weight, serial measurements of central venous pressure, serum and urine concentrations, fluid losses, blood pressure, and the clinical status of the patient. -The parenteral and oral intake and the output of urine, gastric drainage, stools, wound drainage, and perspiration are calculated and are used as the basis for fluid replacement. Fluid excesses s/s: dyspnea, tachycardia, and distended neck veins; auscultate lungs for moist crackles. PE:may be caused by excessive administration of parenteral fluids, extreme caution must be used to prevent fluid overload. Generalized edema: examine the presacral and pretibial areas several times daily. Medications Fluid Volume Excess: Mannitol (Osmitrol), furosemide (Lasix), or ethacrynic acid (Edecrin) may be prescribed to initiate diuresis

Preventing Acute Kidney Injury

-Continually assess renal function (urine output, laboratory values) -Monitor central venous and arterial pressures and hourly urine output of critically ill patients to detect the onset of kidney disease as early as possible. -Pay special attention to wounds, burns, and other precursors of sepsis. -Prevent and treat infections promptly. Infections can produce progressive kidney damage. -Prevent and treat shock promptly with blood and fluid replacement. -Provide adequate hydration to patients at risk for dehydration, including:Before, during, and after surgery -Patients undergoing intensive diagnostic studies requiring fluid restriction and contrast agents (e.g., barium enema, IV pyelograms), especially older patients who may have marginal renal reserve -Patients with neoplastic disorders or disorders of metabolism (e.g., gout) and those receiving chemotherapy -Patients with skeletal muscle injuries (e.g., crush injuries, compartment syndrome)Patients with heat-induced illnesses (e.g., heat stroke, heat exhaustion) -Take precautions to ensure that the appropriate blood is given to the correct patient in order to avoid severe transfusion reactions, which can precipitate kidney disease. -To prevent infections from ascending in the urinary tract, give meticulous care to patients with indwelling catheters. -Remove catheters as soon as possible. -To prevent toxic drug effects, closely monitor dosage, duration of use, and blood levels of all medications metabolized or excreted by the kidneys. Treat hypotension promptly.

Nursing Care During a Seizure

-Provide privacy, and protect the patient from curious onlookers. (The patient who has an aura may have time to seek a safe, private place.) -Ease the patient to the floor, if possible. -Protect the head with a pad to prevent injury (from striking a hard surface). -Loosen constrictive clothing and remove eyeglasses. -Push aside any furniture that may injure the patient during the seizure. -If the patient is in bed, remove pillows and raise side rails. -Do not attempt to pry open jaws that are clenched in a spasm or attempt to insert anything in the mouth during a seizure. Broken teeth and injury to the lips and tongue may result from such an action. -Do not attempt to restrain the patient during the seizure, because muscular contractions are strong and restraint can produce injury. -If possible, place the patient on one side with head flexed forward, which allows the tongue to fall forward and facilitates drainage of saliva and mucus. If suction is available, use it if necessary to clear secretions.

Acute Kidney Injury

-Rapid loss of renal function due to damage to the kidneys. -Potentially life-threatening metabolic complications: metabolic acidosis as well as fluid and electrolyte imbalances -Treatment goal: minimizing long-term loss of renal function -S/S: -AKI is a 50% or greater increase in serum creatinine above baseline (normal creatinine is less than 1 mg/dL) -Urine volume may be normal, or changes may occur. -Possible changes include nonoliguria (greater than 800 mL/day), oliguria (less than 0.5 mL/kg/hr), or anuria (less than 50 mL/day)

Autonomic Dysreflexia Interventions

-The patient is placed immediately in a sitting position to lower blood pressure. -Rapid assessment is performed to identify and alleviate the cause. -The bladder is emptied immediately via a urinary catheter. -If an indwelling catheter is not patent, it is irrigated or replaced with another catheter. -The rectum is examined for a fecal mass. If one is present, a topical anesthetic agent is inserted 10 to 15 minutes before the mass is removed, because visceral distention or contraction can cause autonomic dysreflexia. -The skin is examined for any areas of pressure, irritation, or broken skin. -Any other stimulus that could be the triggering event, such as an object next to the skin or a draft of cold air, must be removed. -If these measures do not relieve the hypertension and excruciating headache, antihypertensive medications may be prescribed and given slowly by the IV route. Any patient with a lesion above the T6 segment is informed that such an episode is possible and may occur even many years after the initial injury

SCI comfort mr

A patient who has had pins, tongs, or calipers placed for cervical stabilization may have a headache or discomfort for several days after the pins are inserted. Pin loosening=infection. If one of the pins become detached, the head is stabilized in a neutral position by one person, while another notifies HCP The skin under the halo vest is inspected for excessive perspiration, redness, and skin blistering, especially on the bony prominences. The vest is opened at the sides to allow the torso to be washed. The liner of the vest should not become wet, because dampness causes skin excoriation. No Powder

Cerebral Edema

Abnormal accumulation of water or fluid in the intracellular space, extracellular space, or both, associated with an increase in the volume of brain tissue Occur in the gray, white, or interstitial matter. These compensatory mechanisms include autoregulation as well as decreased production and flow of CSF. Autoregulation refers to the brain's ability to change the diameter of its blood vessels to maintain a constant cerebral blood flow during alterations in systemic blood Can be caused by contusion, tumor, or abscess; water intoxication (hypo-osmolality); alteration in the blood-brain barrier (protein leaks into the tissue, causing water to follow) Administer osmotic diuretics as prescribed (monitor serum osmolality). Maintain head of bed elevation at 30 degrees. Maintain alignment of the head. Promotes venous return Prevents impairment of venous return through the jugular veins

Pharmacological Management Epilepsy

Achieve seizure control with minimal side effects -Medication therapy controls—rather than cures—seizures. Meds based on type of seizure being treated and the effectiveness and safety of the medications. Treatment usually starts with a single medication. The starting dose and the rate at which the dosage is increased depend on the occurrence of side effects. Levels in the blood are monitored; rate of drug absorption varies among patients. Changing to another medication may be necessary if seizure control is not achieved or if toxicity makes it impossible to increase the dosage. Adjusted because of concurrent illness, weight changes, or increases in stress. Side effects: (1) idiosyncratic or allergic disorders, which manifest primarily as skin reactions; (2) acute toxicity, which may occur when the medication is initially prescribed; and (3) chronic toxicity, which occurs late in the course of therapy.

ATN Medical Management

Acute tubular necrosis is a condition that causes the lack of oxygen and blood flow to the kidneys, damaging them. Tube-shaped structures in the kidneys, called tubules, filter out waste products and fluid. These structures are damaged in acute tubular necrosis. Common interventions for the patient with ATN include drug therapy, dietary management such as protein and electrolyte restrictions, management of fluid and electrolyte imbalances, and renal replacement therapies such as intermittent hemodialysis or continuous renal replacement therapies (CRRTs). Medications Dietary control Protein and electrolyte restrictions Management of fluid and electrolyte imbalances Dialysis or CRRT

Headache

Also known as cephalgia One of the most common physical complaints Headache is a symptom rather than a disease entity; it may indicate organic disease (neurologic or other disease), a stress response, vasodilation (migraine), skeletal muscle tension (tension headache), or a combination of factors. Primary headache has no known organic cause and includes migraine, tension headache, and cluster headache Secondary headache is a symptom with an organic cause such as a brain tumor or aneurysm Headache may cause significant discomfort for the person and can interfere with activities and lifestyle

Permanent access devices

An arteriovenous fistula Arteriovenous grafts Situations may decrease blood flow through the fistula or graft and may cause clotting. The presence and strength of the distal pulse past the fistula or graft are evaluated at least every 8 hours. Inadequate collateral circulation past the fistula or graft may result in loss of this pulse. The physician is notified immediately if no bruit is auscultated, no thrill is palpated, or the distal pulse is absent.

Keppra (levetiracetam)

Anticonvulsant Side effects: Somnolence, dizziness, fatigue Toxic effects: Unknown Used to treat the symptoms of partial onset seizures, tonic-clonic seizures and myoclonic seizures. Keppra may be used alone or with other medications. It is not known if Keppra is safe and effective in children younger than 1 month of age when used to treat partial onset seizures, 6 years old for tonic-clonic seizures, and 12 when used to treat myoclonic seizures. Side effects: unusual changes in mood or behavior, confusion, hallucinations, loss of balance or coordination, extreme drowsiness, feeling very weak or tired, difficulty walking or moving, skin rash, no matter how mild, easily bruising, unusual bleeding, fever, chills, weakness, and other signs of infection

Cerebryx (Fosphenytoin)

Anticonvulsant Used to prevent or control seizures. Cerebyx is used only for a short time, such as 5 days, when other forms of phenytoin cannot be given. Common side effects:dizziness, drowsiness, headache, nausea, vomiting, constipation, dry mouth, itching, tremor, muscle weakness, loss of coordination, ringing in your ears, pain in your hips or back, flushing (warmth, redness, or tingly feeling under your skin), low blood pressure, fast heart rate, spinning sensation, double vision, and changes in taste. treatment of generalized tonic-clonic status epilepticus and prevention and treatment of seizures occurring during neurosurgery. CEREBYX can also be substituted, short-term, for oral phenytoin.

Other migraine drugs

Anticonvulsant agents used for migraine treatment: (divalproex sodium [Depakote], valproate [Depacon], topiramate [Topamax]), beta-blockers (metoprolol [Lopressor], propranolol [Inderal], timolol [Blocadren]), and triptans (frovatriptan [Frova]). Other medications prescribed for migraine -Antidepressant agents (amitriptyline [Elavil], venlafaxine [Effexor]) and additional beta-blockers (atenolol [Tenormin], nadolol [Corgard]) and triptans (naratriptan [Amerge], zolmitriptan [Zomig])

The Patient With an Altered Level of Consciousness

Assess the verbal response through determining the patient's orientation to time, person, and place. Identify the day, date, or season of the year, as well as where they are or the clinicians, family members, or visitors present. Other questions such as "Who is the president?" or "What is the next holiday?" Alertness: ability to open the eyes spontaneously or in response to a vocal or noxious stimulus (pressure or pain). Motor response includes spontaneous, purposeful movement (e.g., the awake patient can move all four extremities with equal strength on command), movement only in response to painful stimuli, or abnormal posturing. Apply a painful stimulus (firm but gentle pressure) to the nail bed or by squeezing a muscle if unresponsive If the patient attempts to push away or withdraw= ("Patient withdraws to painful stimulus") An inappropriate or nonpurposeful response is random and aimless.

NURSING PROCESS: The Patient With Epilepsy

Assessment What limitations are imposed by the seizure disorder? Does the patient participate in any recreational activities? Have any social contacts? Is the patient working, and is it a positive or stressful experience? What coping mechanisms are used? Nursing Dx: Risk for injury related to seizure activity Fear related to the possibility of seizures Ineffective individual coping related to stresses imposed by epilepsy Deficient knowledge related to epilepsy and anticonvulsant medications COMPLICATIONS status epilepticus medication side effects (toxicity). Planning and Goals: Prevention of injury Control of seizures Achievement of a satisfactory psychosocial adjustment Acquisition of knowledge and understanding about the condition Absence of complications. Nursing Interventions PREVENTING INJURY -Injury prevention for the patient with seizures is a priority. Patients for whom seizure precautions are instituted should have pads applied to the side rails while in bed. REDUCING FEAR OF SEIZURES Emphasize meds must be taken on a continuing basis and that drug dependence or addiction does not occur. -Periodic monitoring for adequacy of the treatment regimen, to prevent side effects, and to monitor for drug resistance -Identify precipitating events: emotional disturbances, new environmental stressors, onset of menstruation in female patients, or fever -Encouraged to follow a regular and moderate routine in lifestyle, diet (avoiding excessive stimulants), exercise, and rest (sleep deprivation may lower the seizure threshold). Moderate activity and Keto diet; avoid alcohol -Photic stimulation (e.g., bright flickering lights, television viewing) may precipitate seizures; wearing dark glasses or covering one eye may be preventive. -Tension states (anxiety, frustration) induce seizures in some patients. IMPROVING COPING MECHANISMS -Feelings of stigmatization, alienation, depression, and uncertainty -Cope with the constant fear of a seizure and the psychological consequences -Counseling assists the patient and family to understand the condition and the limitations it imposes Evaluation/Outcome: -Sustains no injury during seizure activity -Adheres to treatment regimen and identifies the hazards of stopping the medication -Can identify appropriate care during seizure; caregivers can do so as well -Indicates a decrease in fear -Displays effective individual coping -Exhibits knowledge and understanding of epilepsy -Identifies the side effects of medications -Avoids factors or situations that may precipitate seizures (e.g., flickering lights, hyperventilation, alcohol) -Follows a healthy lifestyle by getting adequate sleep and eating meals at regular times to avoid hypoglycemia -Absence of complications

Increased ICP Complications

Brainstem herniation, diabetes insipidus, and syndrome of inappropriate antidiuretic hormone (SIADH). Brainstem herniation: pressure builds in the cranial vault and the brain tissue presses down on the brainstem. This increasing pressure on the brainstem results in cessation of blood flow to the brain, leading to irreversible brain anoxia and brain death. Neurogenic diabetes insipidus is the result of decreased secretion of antidiuretic hormone (ADH). The patient has excessive urine output, decreased urine osmolality, and serum hyperosmolarity Therapy consists of administration of fluids, electrolyte replacement, and administration of a synthetic vasopressin SIADH is the result of increased secretion of ADH. The patient becomes volume overloaded, urine output diminishes, and serum sodium concentration becomes dilute. Treatment of SIADH includes fluid restriction (less than 800 mL/day with no free water), which is usually sufficient to correct the hyponatremia. In severe cases, careful administration of a 3% hypertonic saline solution may be therapeutic The change in serum sodium concentration should not exceed a correction rate of approximately 1.3 mEq/L/hr. See Chapters 13 and 52 for further discussion of SIADH.

Dietary changes with dialysis

Concern: The effects of uremia. Goals of nutritional therapy: minimize uremic symptoms and fluid and electrolyte imbalances; to maintain good nutritional status through adequate protein, calorie, vitamin, and mineral intake; and to enable the patient to eat a palatable and enjoyable diet. Restricting dietary protein decreases the accumulation of nitrogenous wastes, reduces uremic symptoms, and may even postpone the initiation of dialysis for a few months. Restriction of fluid is also part of the dietary prescription because fluid accumulation may occur, leading to weight gain, heart failure, and pulmonary edema. Initiation of hemodialysis: some restriction of dietary protein, sodium, potassium, phosphorus, and fluid intake. Protein intake is restricted to about 1.2 to 1.3 g/kg ideal body weight per day; therefore, protein must be of high biologic quality. Sodium is usually restricted to 2 to 3 g/day; fluids are restricted to an amount equal to the daily urine output plus 500 mL/day. The goal for patients on hemodialysis is to keep their interdialytic (between dialysis treatments) weight gain under 1.5 kg. Potassium restriction depends on the amount of residual renal function and the frequency of dialysis.

Bacterial Meningitis nursing care

Critical Illness: Collaborate with the physician, respiratory therapist, and other members of the health care team. Interventions: -Instituting infection control precautions until 24 hours after initiation of antibiotic therapy (oral and nasal discharge is considered infectious) -Assisting with pain management due to overall body aches and neck pain -Rest in a quiet, darkened room -Elevated temperature: antipyretic agents and cooling blankets -Stay hydrated either orally or peripherally -Ensuring close neurologic monitoring Monitor: Neurologic status and vital signs -Pules Ox/ABG's: identify the need for respiratory support if increasing ICP compromises the brainstem. -Trach/Mechanical Ventilation: may be necessary to maintain adequate tissue oxygenation. -BP assessed for early manifestations of shock, which precedes cardiac or respiratory failure. -Rapid IV fluid replacement may be prescribed, but care is taken to prevent fluid overload. Fever also increases the workload of the heart and cerebral metabolism. -ICP will increase in response to increased cerebral metabolic demands; measures are taken to reduce body temperature as quickly as possible. -Protecting the patient from injury secondary to seizure activity or altered LOC -Monitoring daily body weight; serum electrolytes; and urine volume, specific gravity, and osmolality, especially if syndrome of inappropriate antidiuretic hormone (SIADH) is suspected -Preventing complications associated with immobility, such as pressure ulcers and pneumonia Family needs to be informed about the patient's condition

The Patient With a Halo Vest

Demonstrate safe techniques to assist the patient with self-care, hygiene, and ambulation. Demonstrate assessment of frame, traction, tongs, and pins. Demonstrate pin care using correct technique. Demonstrate care of skin, including assessment (e.g., reddened or irritated areas, breakdown). Identify signs and symptoms of infection. Explain the reasons for and the method for changing the vest liner.Identify holistic measures of pain management. Identify signs and symptoms of complications (e.g., venous thromboembolism, respiratory impairment, urinary tract infection). Describe emergency measures if respiratory or other complications develop while the patient is in the halo vest or if the frame becomes dislodged. Relate how to reach primary provider with questions or complications. State time and date of follow-up medical appointments, therapy, and testing. Identify sources of support (e.g., friends, relatives, faith community, spinal cord injury support groups, caregiver support). Identify the need for health-promotion, disease prevention, and screening activities. ADLs, activities of daily living; IADLs, independent activities of daily living.

Detecting Increasing Intracranial Pressure (ICP):Early Signs and Symptoms

Disorientation, restlessness, increased respiratory effort, purposeless movements, and mental confusion. The brain cells responsible for cognition are extremely sensitive to decreased oxygenation. -Pupillary changes and impaired extraocular movements. These occur as the increasing pressure displaces the brain against the oculomotor and optic nerves (cranial nerves II, III, IV, and VI), which arise from the midbrain and brainstem Weakness in one extremity or on one side of the body. This occurs as increasing ICP compresses the pyramidal tracts. Headache that is constant, increasing in intensity, and aggravated by movement or straining

Kayexalate

Due to decreased GFR Hyperkalemia is common in AKI, especially if the patient is hypercatabolic. Hyperkalemia occurs when potassium excretion is reduced as a result of the decrease in GFR. Sudden changes in the serum potassium level can cause dysrhythmias, which may be fatal. Works by exchanging sodium ions for potassium ions in the intestinal tract. -Sorbitol may be given in combination with Kayexalate to induce a diarrhea-type effect (it induces water loss in the GI tract). If Kayexalate retention enema is given (the colon is the major site of potassium exchange), a rectal catheter with a balloon may be used to facilitate retention if necessary. -The patient should retain the Kayexalate for at least 30 to 60 minutes (preferable 6 to 10 hours) to promote potassium removal -Afterward, a cleansing enema may be prescribed to remove remaining medication as a precaution against fecal impaction.

Pharmacology and AKI

Examples of commonly used agents that require adjustment are antibiotic medications (especially aminoglycosides), digoxin (Lanoxin), phenytoin (Dilantin), ACE inhibitors, and magnesium-containing agents. Meds to improve AKI outcomes: Diuretic agents are often used to control fluid volume, but they have not been shown to improve recovery from AKI AKI w/severe acidosis: the arterial blood gases and serum bicarbonate levels (CO2) must be monitored because the patient may require sodium bicarbonate therapy or dialysis. -If respiratory problems develop, appropriate ventilatory measures must be instituted. The elevated serum phosphate level may be controlled with phosphate-binding agents (e.g., calcium or lanthanum carbonate) that help prevent a continuing rise in serum phosphate levels by decreasing the absorption of phosphate from the intestinal tract.

To receive tPA the patient should have a:

Eligibility Criteria for Tissue Plasminogen Activator Administration Age ≥18 years Clinical diagnosis of ischemic stroke Time of onset of stroke known and is less than 3 hours before treatment Systolic blood pressure ≤185 mm Hg; diastolic ≤110 mm Hg No minor stroke or rapidly resolving stroke No seizure at onset of stroke Prothrombin time ≤15 seconds or international normalized ratio ≤1.7 (if taking an anticoagulant, the same guidance is used) Not received heparin during the past 48 hours with elevated partial thromboplastin time Platelet count ≥100,000/mm3 Glucose >50 mg/dL No prior intracranial hemorrhage, neoplasm, arteriovenous malformation, or aneurysm No major surgical procedures or serious trauma within 14 days No stroke, serious head injury, or intracranial surgery within 3 months No gastrointestinal or urinary bleeding within 21 days No pregnancy tPA (tissue plasminogen activator): for ischemia strokes ONLY not hemorrhagic! How does it work? It dissolves the clot within the blood vessel by activating the protein that causes fibrinolysis. REMEMBER: It must be given within 3 hours from the onset of stroke symptoms. It can be given 3 to 4.5 hours after onset IF strict criteria is met. CT of head that is NEGATIVE for hemorrhage labs within normal limits (glucose, INR, platelets) BP needs to be controlled SBP <185 and DBP <110 glucose controlled (increases rise of hemorrhage) not receiving heparin or other types of anticoagulants Nurse's Role: monitor for BLEEDING, neuro checks around the clock, blood pressure medication if needed for hypertension, vital signs, labs, glucose, preventing injury (bedrest), avoid unnecessary venipunctures, avoid IM injections, will go to ICU to be monitored

ESRD Cardiovascular

Engorged neck veins Hyperkalemia Hyperlipidemia Hypertension Pericardial effusion Pericardial friction rub Pericardial tamponade Pericarditis Periorbital edema Pitting edema (feet, hands, sacrum) Hematologic Anemia Thrombocytopenia

eopoetin alfa

Epogen, Procrit Many animal studies have shown that EPO administration protects kidney tissue from damage and improves renal function in ischemia-reperfusion (IR) and contrast-induced injury models of AKI in which EPO reduced kidney dysfunction by decreasing apoptosis

Premonitory Phase

Experienced by more than 80% of adult migraine sufferers, with symptoms that occur hours to days before a migraine headache Symptoms: depression, irritability, feeling cold, food cravings, anorexia, change in activity level, increased urination, diarrhea, or constipation. A current theory regarding premonitory symptoms is that they involve the neurotransmitter dopamine.

Neurogenic shock treatment

General treatment & Atropine for bradycardia & stabilize C-spine & methylprednisolone within 8 hours of injury

Nurse management of Headaches

Goal: pain relief. It is reasonable to try nonpharmacologic -First priority: treat the acute event of the headache and the second is to prevent recurrent episodes. -Prevention involves patient education regarding precipitating factors, possible lifestyle or habit changes that may be helpful, and pharmacologic measures. -Individualized treatment depends on the type of headache and differs for migraine, cluster headaches, cranial arteritis, and tension headache. Treat acute episode: A migraine or a cluster headache in the early phase requires abortive medication therapy instituted as soon as possible. Comfort measures: a quiet, dark environment; elevation of the head of the bed to 30 degrees; and symptomatic treatment (i.e., administration of antiemetic medication) Tension headache: local heat or massage. Administer analgesic agents, antidepressant medications, and muscle relaxants. Regular sleep, meals, exercise, relaxation, and avoidance of dietary triggers may be helpful in avoiding headaches Stress reduction techniques, such as biofeedback, exercise programs, and meditation

AKI diet

Higher-than-normal basal requirement Provide adequate energy, protein, and micronutrients 25 to 35 kcal/kg of ideal body weight per day Restricted Protein Sodium Potassium Fluid intake (output + 600-1000 mL) Energy expenditure in catabolic patients with acute renal failure is much higher than normal. Dialysis also contributes to protein catabolism. The overall goal of dietary management for acute renal failure is provision of adequate energy, protein, and micronutrients to maintain homeostasis in patients who may be extremely catabolic. Nutritional recommendations: Caloric intake of 25 to 35 kcal/kg of ideal body weight per day Protein intake of no less than 0.8 g/kg body weight. Patients who are extremely catabolic should receive 1.5 to 2 g/kg of ideal body weight per day, 75% to 80% of which contains all the required essential amino acids. Sodium intake of 0.5 to 1.0 g/day Potassium intake of 20 to 50 mEq/day Calcium intake of 800 to 1200 mg/day Fluid intake equal to the volume of the patient's urine output plus an additional 600 to 1000 mL/day

phenytoin: (Dilantin)

Hydantoins THERAPEUTIC USE• Tonic-clonic seizures• Partial seizures ADVERSE DRUG REACTIONS • Drowsiness and other CNS effects• Gingival hyperplasia (abnormal growth of tissue around gums)• Skin rash (epidermal necrolysis, Stevens-Johnson syndrome)• Withdrawal symptoms following long-term use (seizures) INTERVENTIONS• Monitor client for these side effects• Refer clients for dental care and teaching about oral hygiene techniques• Monitor for rash; phenytoin should be discontinued if rash occurs• Reduce phenytoin dosage gradually ADMINISTRATION• Give with meals to prevent GI symptoms• Inject IV form slowly, using correct dilution• Monitor vital signs during IV administration to prevent cardiac dysrhyth-mias and hypotension• Due to narrow therapeutic range, carefully monitor plasma levels, which should remain between 10 and 20 mcg/mL. Levels greater than 30 mcg/mL can be toxic. CLIENT INSTRUCTIONS• Instruct client not to drive or perform other hazardous activities if expe-riencing CNS side effects.• Instruct client to notify provider if CNS effects occur.• Instruct client to obtain regular dental checkups.• Instruct, as needed, in brushing with soft-bristled toothbrush, gum mas-sage, and flossing.• Instruct client to notify provider if rash occurs.• Instruct client not to stop taking phenytoin abruptly. CONTRAINDICATIONS• Pregnancy Risk - teratogenic• Skin rash• Bradycardia or heart block• Previous allergy to hydantoins• Seizures caused by low blood sugar PRECAUTIONS• Liver or kidney disease• Cardiac dysfunction• Diabetes mellitus• Older adults• Debilitated clients• Alcohol use disorder• Respiratory dysfunction INTERACTIONS• IV phenytoin incompatible in solution with many other drugs and with dextrose solution.• Diazepam, isoniazid, cimetidine, and valproic acid increase levels of phenytoin.• Alcohol use may either increase or decrease phenytoin levels.• CNS depressants increase sedative effects.• Phenobarbital and carbamazepine can decrease phenytoin levels.• Use can decrease efficacy of oral contraceptives.

AKI Pharmacologic Therapy: hyperkalemia

Hyperkalemia: -monitored for thru serial serum electrolyte levels (potassium value greater than 5.0 mEq/L [5 mmol/L]), ECG changes (tall, tented, or peaked T waves) -S/S: irritability, abdominal cramping, diarrhea, paresthesia, and generalized muscle weakness; slurred speech, difficulty breathing, paresthesia, and paralysis. -The elevated potassium levels may be reduced by administering cation-exchange resins (sodium polystyrene sulfonate [Kayexalate]) orally or by retention enema. -If the patient is hemodynamically unstable (low blood pressure, changes in mental status, dysrhythmia), IV dextrose 50%, insulin, and calcium replacement may be given to shift potassium back into the cells. -The shift of potassium into the intracellular space is temporary, so arrangements for dialysis need to be made on an emergent basis.

AKI Predisposing factors

Hypertension Diabetes Immunological disease Hereditary disorders Hypotensive episodes Exposure to nephrotoxic agents For example, dysuria, frequency, incontinence, nocturia, pyuria, and hematuria can be indicative of urinary tract infection. The history provides clues about medical conditions that predispose the patient to AKI, including diabetes mellitus, hypertension, immunological diseases, and any hereditary disorders, such as polycystic disease. The medical record is reviewed to elicit additional risk factors, such as hypotensive episodes or any surgical or radiographic procedures performed. Information regarding exposure to potential nephrotoxins is extremely important—antibiotics, such as aminoglycosides.

Sumaptriptan

Imitrex THERAPEUTIC USE: Relieve symptoms of existing migraine or cluster headache ADVERSE DRUG REACTIONS: Chest pressure or "heaviness"; may progress to angina pain caused by coronary vasospasm; CNS effects: tingling sensation, vertigo INTERVENTIONS• Monitor for this effect• Monitor vital signs closely after first dose• Monitor for this effect ADMINISTRATION• Give orally, SC, or by nasal spray• Use nasal spray by spraying once into a single nostril; may repeat after 2 hr• Single dose ranges from 5 to 20 mg• Maximum dose is 40 mg in 24 hr• Give one SC injection and repeat once after 1 hr if no relief; no more than two doses in 24 hr• Give one oral tablet; repeat once after 2 hr if no relief• Single dose ranges from 25 mg to 100 mg• Maximum dose is 200 mg in 24 hr CLIENT INSTRUCTIONS• Instruct client to notify provider at once for chest pressure or tightness/heaviness in back, jaw, throat that does not spontaneously resolve• Instruct client to report CNS symptoms to provider at next visit CONTRAINDICATIONS• Coronary artery disease, angina, previous MI, severe hypertension• Peripheral vascular disease (PVD)• Older adults• Stroke• Use of MAOI within last 2 weeks• Use of another triptan within last 24 hr PRECAUTIONS• Liver or kidney insufficiency• Coronary artery disease risk factors• Seizure disorder• Blood pressure elevation• Serotonin syndrome• Chest, jaw, or neck tightness• Fertility impairment INTERACTIONS• MAO inhibitors taken within 2 weeks can cause sumatriptan toxicity• Ergotamine or another triptan clients use within 24 hr of sumatriptan increases chance of angina• Serotonin agonists with sumatriptan can cause serotonin syndrome• Herbal St. John's wort can cause toxicity

Bacterial Meningitis

Inflammation of the meninges, which cover and protect the brain and spinal cord Meningitis can be the main reason a patient is hospitalized, or it can develop during hospitalization; it is classified as septic or aseptic. Septic meningitis is caused by bacteria. The bacteria Streptococcus pneumoniae and Neisseria meningitidis are responsible for the majority of cases of bacterial meningitis in adults. Outbreaks of N. meningitidis infection are most likely to occur in dense community groups, such as college campuses and military installations. Although infections occur year-round, the peak incidence is in the winter and early spring. Factors that increase the risk: -Tobacco use and viral upper respiratory infection: increase the amount of droplet production -Otitis media and mastoiditis increase the risk of bacterial meningitis: bacteria can cross the epithelial membrane and enter the subarachnoid space. -Immune system deficiencies are also at greater risk for development of bacterial meningitis

Pros/Cons Continuous Ambulatory Peritoneal Dialysis

It offers the advantages of greater clearance of higher molecular-weight substances than during hemodialysis, good control of blood pressure, marked improvement of anemia, and unrestricted diet. The main advantage of CAPD is that the equipment is portable. This gives you more freedom to travel away from your house. you may be able to take your CAPD equipment to your workplace. But you'll need to spend at least 2 hours a day performing dialysis. But you need to keep and maintain a dialysis machine (and the associated equipment) in your house, which will not be practical for some people.

Ativan/Valium

Lorazepam/Diazepam General Anesthesia/Benzodiazepine THERAPEUTIC USE• Sedation before general anesthesia• Conscious sedation with induction of amnesia during procedures, such as endoscopy• Supplement to inhalation anesthesia for surgeries ADVERSE DRUG REACTIONS • Amnesia (memory loss from time prior to injection of midazolam)• Cardiac or respiratory arrest INTERVENTIONS• Monitor for this effect• Inject IV bolus slowly and wait at least 2 minutes before giving a second dose• Have resuscitation equipment at hand• Monitor vital signs carefully during and after procedure ADMINISTRATION• Can be given orally to children preop• May administer IM into large muscle mass for conscious sedation• Give IV bolus or infusion for induction of anesthesia or conscious seda-tion• Do not give bolus dose to neonates• May combine with an opioid for conscious sedation CLIENT INSTRUCTIONS• Advise client that memory loss was caused by drug• Advise client that frequent monitoring will occur before, during, and after procedure CONTRAINDICATIONS• Pregnancy Risk teratogenic, lactation• Obstetric delivery• Sensitivity to benzodiazepines• Glaucoma PRECAUTIONS• Neuromuscular disorders• Cardiac, pulmonary, or renal disorders INTERACTIONS• CNS depressants, anticonvulsants increase sedation from midazolam• Cimetidine may cause midazolam toxicity• Herbal products may increase or decrease effect of midazolam

Spinal Cord Injury

Mechanisms of injuries that may result in SCI include hyperflexion, hyperextension, axial loading, rotation, and penetrating trauma. The initial treatment:ABCs of resuscitation, spinal immobilization, and prevention of further injury through surgical stabilization of the spine. -A complete sensory and motor neurological examination is performed, and x-ray studies of the cervical spine are obtained. -A spinal CT scan may be performed to rule out occult injury; determine the approximate level of SCI because higher cervical spine injuries may result in the loss of phrenic nerve innervations, compromising the patient's ability to breathe spontaneously. Loss of sympathetic output, resulting in distributive shock with hypotension and bradycardia. Blood pressure may respond to IV fluids, but vasopressor therapy is often required to compensate for the loss of sympathetic innervation and resultant vasodilation.

Prevention of bacterial meningitis

Meningococcal conjugated vaccine be given to youth at 11 to 12 years of age, with a booster dose at 16 years of age. First-year college students and members of the military who have not been vaccinated are at higher risk. Close contact: treated with antimicrobial chemoprophylaxis using rifampin (Rifadin), ciprofloxacin hydrochloride (Cipro), or ceftriaxone sodium (Rocephin). Therapy started within 24 hours after exposure because a delay limits the effectiveness of the prophylaxis. Vaccination should also be considered as an adjunct to antibiotic chemoprophylaxis for anyone living with a person who develops meningococcal infection. Vaccination against Haemophilus influenzae and S. pneumoniae should be encouraged for children and adults who are at-risk

SCI: MONITORING AND MANAGING POTENTIAL COMPLICATIONS

Monitor for s/s of DVT and PE: Chest pain, shortness of breath, and changes in arterial blood gas values must be reported promptly to the primary provider. -The circumferences of the thighs and calves are measured and recorded daily; further diagnostic studies are performed if a significant increase is noted. -high risk for thrombophlebitis for several months after the initial injury. -paraplegia or tetraplegia are at increased risk for the rest of their lives. Anticoagulation should be initiated within 72 hours of injury and continued for at least 3 months The use of low-molecular-weight heparin or low-dose unfractionated heparin may be followed by long-term oral anticoagulation (i.e., warfarin [Coumadin]). Additional measures such as range-of-motion exercises, antiembolism stockings, and adequate hydration are important preventive measures. Orthostatic Hypotension For the first 2 weeks after SCI BP tends to be unstable and can be quite low. Orthostatic hypotension common problem for patients with lesions above T7. Monitor of vital signs before and during position changes is essential. Optimization of fluid status and vasopressor medication can be used to treat the profound vasodilation. Antiembolism stockings should be applied to improve venous return from the lower extremities. Abdominal binders may also be used to encourage venous return and provide diaphragmatic support when the patient is upright Activity should be planned in advance, and adequate time should be allowed for a slow progression of position changes from recumbent to sitting and upright. Tilt tables frequently are helpful in assisting patients to make this transition.

Geriatric Considerations AKI

Normal decline owing to aging: -Renal blood flow gradually diminishes at a rate of 10% per decade after 40. -Decrease in renal mass, the number of glomeruli, and peritubular density. -Decreased muscle mass leads decreased creatinine production. -Age-related changes in renin and aldosterone levels also occur that can lead to fluid and electrolyte abnormalities. -Increased risk of hyperkalemia (with possible cardiac conduction abnormalities), a decreased ability to conserve sodium, and a tendency to develop volume depletion and dehydration. -Slower to correct an increase in acids, causing a prolonged metabolic acidosis and the subsequent shifting of potassium out of cells and worsening hyperkalemia. Decreased responsiveness to ADH that may exacerbate volume depletion and dehydration. Comorbidities Diabetes Hypertension Prescribed medications -Other tubular changes include a diminished ability to excrete drugs, including radiocontrast dyes used in diagnostic testing, which necessitates a decrease in drug dosing to avoid nephrotoxicity. -Many medications, including antibiotics, require dose adjustments as kidney function declines. Drug databases are available for appropriate dosing.

Nursing Management: Status Epilepticus

Ongoing assessment and monitoring of respiratory and cardiac function Risk for delayed depression of respiration and blood pressure secondary to administration of anticonvulsant medications and sedatives to halt the seizures. Monitor and document the seizure activity and the patient's responsiveness. Side-lying position (assist in draining pharyngeal secretions) Suction equipment for aspiration. The IV line is closely monitored, because it may become dislodged during seizures. Long-term anticonvulsant therapy= risk for fractures resulting from bone disease (osteoporosis, osteomalacia, and hyperparathyroidism), which is a side effect of therapy Protect pt from injury with the use of seizure precautions and is monitored closely; nurses should protect themselves too

B.M. Patho

Originate in one of two ways: 1)through the bloodstream as a consequence of other infections 2)by direct spread, such as might occur after a traumatic injury to the facial bones or secondary to invasive procedures. The N. meningitidis bacteria exists in the throats and nasal passages of approximately 10% of the general population and is transmitted by secretion or aerosol contamination Bacterial or meningococcal meningitis also occurs as an opportunistic infection in patients with acquired immune deficiency syndrome (AIDS) and as a complication of Lyme disease Once the causative organism enters the bloodstream, it crosses the blood-brain barrier and proliferates in the cerebrospinal fluid (CSF). The host immune response stimulates the release of cell wall fragments and lipopolysaccharides, facilitating inflammation of the subarachnoid and pia mater. Because the cranial vault contains little room for expansion, the inflammation may cause increased intracranial pressure (ICP). -CSF circulates through the subarachnoid space, where inflammatory cellular materials from the affected meningeal tissue enter and accumulate. Prognosis: depends on the causative organism, the severity of the infection and illness, and the timeliness of treatment. Acute fulminant presentation may include adrenal damage, circulatory collapse, and widespread hemorrhages This syndrome is the result of endothelial damage and vascular necrosis caused by the bacteria. Complications include visual impairment, deafness, seizures, paralysis, hydrocephalus, and septic shock.

Dialysis Vascular Access

Percutaneous catheters Arteriovenous fistulas Grafts External shunts An essential component of all the renal replacement therapies is adequate, easy access to the patient's bloodstream. Various types of vascular access devices are used for hemodialysis: percutaneous venous catheters, arteriovenous fistulas, and arteriovenous grafts. Temporary access devices are associated with a high risk for infection.

Peritoneal Dialysis

Peritoneal dialysis is the removal of solutes and fluid by diffusion through a patient's semipermeable membrane (the peritoneal membrane) with a dialysate solution that has been instilled into the peritoneal cavity. The peritoneal membrane surrounds the abdominal cavity and lines the organs inside the abdominal cavity. This renal replacement therapy is not commonly used for the treatment of AKI because of its comparatively slow ability to alter biochemical imbalances and because of its high risk for peritonitis. Removal of solutes and fluids using the peritoneal membrane as a filter Rarely used in the critical care setting because it is less efficient High risk of peritonitis

Medications to prevent future embolic strokes - rationale, mechanism of action, patient teaching

Platelet-inhibiting medications, including aspirin, extended-release dipyridamole plus aspirin (Aggrenox), and clopidogrel decrease the incidence of cerebral infarction in patients who have experienced TIAs and stroke from suspected Statins reduce coronary events and ischemic strokes. The most current stroke prevention guideline now includes the recommendation of a statin even if the low-density lipoprotein (LDL) cholesterol is below 100 mg/dL and there is no evidence of atherosclerotic cardiovascular disease (coronary artery disease/myocardial infarction, hypertensive heart disease and peripheral arterial disease) Simvastatin (Zocor), to include secondary stroke prevention. After the acute stroke period, antihypertensive medications are also used, if indicated, for secondary stroke prevention. Preferred drugs include angiotensin-converting enzyme (ACE) inhibitors and diuretics, or a combination of both Endovascular treatment

posturing

Posturing may be decorticate or decerebrate The most severe neurologic impairment results in flaccidity. The motor response cannot be elicited or assessed when the patient has been given pharmacologic paralyzing agents (i.e., neuromuscular blocking agents). Abnormal posture response to stimuli. Decorticate posturing and flexion of the upper extremities, internal rotation of the lower extremities, and plantar flexion of the feet. Decerebrate posturing, involving extension and outward rotation of upper extremities and plantar flexion of the feet.

AKI RIFLE

R (Risk)-Increased serum creatinine 1.5 × baseline OR GFR decreased ≥25%; 0.5 mL/kg/hr for 6 hours I (Injury)-Increased serum creatinine 2 × baseline OR GFR decreased ≥50%; 0.5 mL/kg/hr for 12 hours F (Failure)-Increased serum creatinine 3 × baseline OR GFR decreased ≥75% OR serum creatinine ≥354 mmol/L with an acute rise of at least 44 mmol/L <0.3 mL/kg/hr for 24 hours OR Anuria for 12 hours L (Loss)-Persistent acute kidney injury = complete loss of kidney function >4 weeks E (ESKD): ESKD >3 months

Intrarenal AKI

Result of actual parenchymal damage to the glomeruli or kidney tubules. -Acute tubular necrosis (ATN), or AKI in which there is damage to the kidney tubules, is the most common type of intrinsic AKI. -Characteristics of ATN are intratubular obstruction, tubular back leak (abnormal reabsorption of filtrate and decreased urine flow through the tubule), vasoconstriction, and changes in glomerular permeability. -These processes result in a decrease of GFR, progressive azotemia, and fluid and electrolyte imbalances. CKD, diabetes, heart failure, hypertension, and cirrhosis can lead to ATN Prolonged renal ischemia resulting from: -Hemoglobinuria (transfusion reaction, hemolytic anemia) -Rhabdomyolysis/myoglobinuria (trauma, crush injuries, burns) -Pigment nephropathy (associated with the breakdown of blood cells containing pigments that in turn occlude kidney structures) Nephrotoxic agents such as: -Aminoglycoside antibiotics (gentamicin, tobramycin) -Angiotensin-converting enzyme inhibitors -Heavy metals (lead, mercury) -Nonsteroidal anti-inflammatory drugs -Radiopaque contrast agents -Solvents and chemicals (ethylene glycol, carbon tetrachloride, arsenic) Infectious processes such as: -Acute glomerulonephritisAcute pyelonephritis

Other types of Headaches

Tension-type headache Trigeminal autonomic cephalalgias include cluster headaches and paroxysmal hemicrania. Cluster headaches are relatively uncommon and seen more frequently in men than in women Types of headaches not subsumed under these categories fall into the other primary headache group and include headaches triggered by cough, exertion, and sexual activity. Cranial arteritis is a cause of headache in the older population, reaching its greatest incidence in those older than 70 years of age. Inflammation of the cranial arteries is characterized by a severe headache localized in the region of the temporal arteries. A secondary headache is a symptom associated with other causes, such as a brain tumor, an aneurysm, or lumbar puncture. Although most headaches do not indicate serious disease, persistent headaches require further investigation. Serious disorders related to headache include brain tumors, subarachnoid hemorrhage, stroke, severe hypertension, meningitis, and head injuries.

CPP

The CPP is calculated by subtracting the ICP from the mean arterial pressure (MAP). If the MAP is 100 mm Hg and the ICP is 15 mm Hg, then the CPP is 85 mm Hg. The normal CPP is 70 to 100 mm Hg As ICP rises and the autoregulatory mechanism of the brain is overwhelmed, the CPP can increase to greater than 100 mm Hg or decrease to less than 50 mm Hg. CPP of less than 50 mm Hg experience irreversible neurologic damage CPP must be maintained at 70 to 80 mm Hg to ensure adequate blood flow to the brain. If ICP is equal to MAP, cerebral circulation ceases.

Increased ICP: Clinical Manifestations

The earliest sign of increasing ICP is a change in LOC. Agitation, slowing of speech, and delay in response to verbal suggestions may be early indicators. Any sudden change in the patient's condition, such as restlessness (without apparent cause), confusion, or increasing drowsiness, has neurologic significance. These signs may result from compression of the brain due to swelling from hemorrhage or edema, an expanding intracranial lesion (hematoma or tumor), or a combination of both. As ICP increases, the patient becomes stuporous, reacting only to loud or painful stimuli. Serious impairment of brain circulation is probably taking place, and immediate intervention is required. As neurologic function deteriorates further, the patient becomes comatose and exhibits abnormal motor responses in the form of decortication (abnormal flexion of the upper extremities and extension of the lower extremities), decerebration (extreme extension of the upper and lower extremities), or flaccidity If the coma is profound and irreversible with no known confounding factors, brainstem reflexes are absent, and respirations are impaired or absent, the patient may be evaluated for brain death

Phenytoin toxicity ***

The manifestations of drug toxicity: gingival hyperplasia (swollen and tender gums) can be associated with long-term use of phenytoin -Periodic physical and dental examinations and laboratory tests are performed for patients receiving medications that are known to have hematopoietic, genitourinary, or hepatic effects.

Medical Management of other headaches

The medical management of an acute attack of cluster headaches may include 100% oxygen by facemask for 15 minutes, subcutaneous sumatriptan, or intranasal zolmitriptan The medical management of cranial arteritis consists of early administration of a corticosteroid to prevent the possibility of loss of vision due to vascular occlusion or rupture of the involved artery. The patient is instructed not to stop the medication abruptly, because this can lead to relapse. Analgesic agents are prescribed for comfort.

Migraine Phases

The migraine with aura can be divided into four phases: premonitory, aura, the headache, and recovery (headache termination and postdrome)

Increased ICP

The rigid cranial vault contains brain tissue (1400 g), blood (75 mL), and CSF (75 mL). The volume and pressure of these three components are usually in a state of equilibrium and produce the ICP. ICP is usually measured in the lateral ventricles, with the normal pressure being 0 to 10 mm Hg, and 15 mm Hg being the upper limit of normal The Monro-Kellie hypothesis, also known as the Monro-Kellie doctrine, explains the dynamic equilibrium of cranial contents. The hypothesis states that because of the limited space for expansion within the skull, an increase in any one of the components causes a change in the volume of the others. Because brain tissue has limited space to expand, compensation typically is accomplished by displacing or shifting CSF, increasing the absorption or diminishing the production of CSF, or decreasing cerebral blood volume. Without such changes, ICP begins to rise. Under normal circumstances, minor changes in blood volume and CSF volume occur constantly as a result of alterations in intrathoracic pressure (coughing, sneezing, straining), posture, blood pressure, and systemic oxygen and carbon dioxide levels

Dialysis

The separation of solutes by differential diffusion through a porous or semipermeable membrane that is placed between two solutions. Diffusion (or clearance) is the movement of solutes such as urea from the patient's blood to the dialysate cleansing fluid, across a semipermeable membrane (the hemofilter). Ultrafiltration is the removal of plasma water and some low-molecular weight particles by using a pressure or osmotic gradient. Ultrafiltration is primarily aimed at controlling fluid volume, whereas dialysis is aimed at decreasing waste products and treating fluid and electrolyte imbalances.

Triptans

These agents cause vasoconstriction, reduce inflammation, and may reduce pain transmission. The five triptans in routine clinical use include sumatriptan (Imitrex), naratriptan (Amerge), rizatriptan (Maxalt), zolmitriptan (Zomig), and almotriptan (Axert) Best results are achieved with early use of triptans; oral dosing takes effect within 20 to 60 minutes of taking the drug and if needed may be repeated in 2 to 4 hours. Contraindicated in patients with ischemic heart disease. Careful administration and dosing instructions to patients are important to prevent adverse reactions such as increased blood pressure, drowsiness, muscle pain, sweating, and anxiety. Interactions are possible if the medication is taken in conjunction with St. John wort Available in a variety of formulations, such as nasal sprays, inhalers, conventional tablet, disintegrating tablet, suppositories, or injections. The nasal sprays are useful for patients experiencing nausea and vomiting The triptans are considered first-line treatment of the management of moderate to severe migraine pain.

Cluster headache

Unilateral and come in clusters of one to eight daily, with excruciating pain localized to the eye and orbit and radiating to the facial and temporal regions. The pain is accompanied by watering of the eye and nasal congestion. Each attack lasts 15 minutes to 3 hours and may have a crescendo-decrescendo pattern The headache is often described as penetrating. Trigeminal autonomic cephalalgias type Relatively uncommon and seen more frequently in men than in women

Phases of Acute Kidney Injury

initiation, oliguria, diuresis, and recovery. -The initiation period begins with the initial insult and ends when oliguria develops. oliguria: increase in the serum concentration of substances usually excreted by the kidneys (urea, creatinine, uric acid, organic acids, and the intracellular cations [potassium and magnesium]). this phase, uremic symptoms first appear and life-threatening conditions such as hyperkalemia develop. -The diuresis period: gradual increase in urine output, which signals that glomerular filtration has started to recover. -Laboratory values stabilize and eventually decrease. -Renal function may still be markedly abnormal; uremic symptoms may still be present, expert medical and nursing management continues -observed closely for dehydration during this phase; if dehydration occurs, the uremic symptoms are likely to increase. The recovery period- signals the improvement of renal function and may take 3 to 12 months. -1% to 3% reduction in the GFR may occur -Some: decreased renal function with increasing nitrogen retention but actually excrete normal amounts of urine (1 to 2 L/day).