Neurologic

Conditions
Part 2
NURS4321
 Spinal cord injuries:
p. 2087-2102;

Seizure Disorders/Epilepsy:
p. 2030-2038
Agenda Headache: p. 2038-2042

Meningitis: p. 2105-2107 ,
article on D2L
Spinal Cord Injury (SCI)
Spinal Cord Injury

• Usually from sudden

traumatic blow to the
spine

• Fracture, dislocation or
compression of vertebrae

• Destruction of nerve cells

that carry signals
up/down spinal cord
 Risk factors

• Age
• Gender
• Alcohol/drug use

• What are some primary

prevention strategies
related to SCI?
Spinal Cord Injuries
• Vertebrae most commonly involved
in SCI are:
• C5, C6, C7
• T12
• L1
• Why?
– Because there is a greater range of
mobility
 Question

• What are some signs

and symptoms of SCI
after an accident?

This Photo by Unknown Author is licensed under CC BY-SA

 Emergency
Management
• Prevention of further damage
– How?
• Immobilization
• Extrication
• Stabilization

• ABC’s
– What is the leading cause of
death with high cervical SCI?
• Pneumonia, PE, Pulmonary
edema
Spinal Cord Injury
-Imaging Tests

• Plain xray - must adequately depict

all vertebrae

• CT scan - when plain xray is

inadequate or fails to visualize
segments of the axial skeleton

• MRI - for suspected spinal cord

lesions, ligamentous injuries, other
soft-tissue injuries or pathology
Spinal Cord Injury -Lab Tests
• ABGs – evaluate adequacy of
oxygenation/ ventilation

• Lactate levels - monitor

perfusion status in shock
states

• Hgb and/or Hct levels - initially

and serially to detect or
monitor sources of blood loss

• Urinalysis - to detect any

associated GU injury

• What else?
Spinal Cord Injury -
Pharmacotherapy

• Goal to improve motor

function and sensation

• Methylprednisolone
(Solu-Medrol) used
within 8 hrs to reduce
secondary effects of SCI

• Pregabalin (Lyrica) for

management of
neuropathic pain
associated with SCI

This Photo by Unknown Author is licensed under CC BY

 Neurogenic Shock

• Loss of ANS function below

level of injury
• Affects vital organs
•  BP HR cardiac output
Potential • Pts require support until body
can adapt
Complications
with SCI Spinal Shock

• Sudden depression of reflex

activity below level of injury
• Esp reflexes that innervate
bowel/bladder function
 Medical emergency

Usually occurs in SCI above T6

Autonomic Reaction of autonomic nervous

Bowel impaction
Urinary retention
system to overstimulation
Dysreflexia
Pressure ulcer

s/s BP, pounding headache, profuse

sweating, nasal congestion, piloerection,
bradycardia

**Treatment = removal of triggering

stimuli**
Potential Long-term Complications
with Spinal Cord Injury
DVT
• Why?: immobility
• What is the risk?: PE, MI
• How do you assess?:
• Management, pharmacologic, non-pharmacologic
Pneumonia
• Why?: accessory muscles of respiration are lost,
cant clear secretions
• Nursing management to prevent?: chest physio,
cough assist, humidification and hydration, monitor
for deterioration
• How to monitor for it?: ABGs, vital capacity, pulse
oximetry
Potential Long-term Complications
with Spinal Cord Injury
Pressure Ulcers

• Why are pts at risk?

• Immobility, poor circulation
• How to prevent (nursing measures)? turning and
positioning, skin care
• How to monitor?: skin assessments, Braden scale

Contractures

• Why?: immobility
• How to prevent (nursing measures)? ROM
Seizures
 Abnormal episodes of motor,
sensory, autonomic, or
psychic activity (or a
combination of these)
Results from a sudden,
abnormal, uncontrolled
Seizures electrical discharge from
cerebral neurons
May involve part or all of
brain
 What are Some
Conditions that
Cause Seizures?

• Head injury
- Brain tumour
- Cerebrovascular disease
---- hypertension
- Hypoxemia
- *Central nervous system infections
- Metabolic and toxic conditions
- Drug and alcohol withdrawal
- Allergic reaction
 Causes of Seizures
Cerebrovascular
Head injury Brain tumour disease
• hypertension

Central nervous
Metabolic and
Hypoxemia system
toxic conditions
infections

Drug and
alcohol Allergic reaction Others?
withdrawal
 Aimed at determining

• Type of seizures
• Frequency and severity
• Factors that precipitate them

Assessment Developmental history

Illnesses, past relevant

medical history

Head injury hx
 EEG –electrical activity of the brain

MRI – to detect brain lesions, cerebral

degenerative changes, cerebrovascular
Diagnostic abnormalities

Assessment

Bloodwork. What and why?

-electrolytes (potassium and sodium know
them), glucose (may be caused by
hypoglycemia), phenytoin, WBC, Urine culture
(older adults), creatinine, ABGs
 Recurring seizures

Can be primary
(idiopathic). What
does this mean?- No
The known cause

Epilepsies Secondary, symptom of

another condition.
-brain tumor

International
see chart in
Classification of text
Seizures
 Simple
Partial
Seizures
Complex
Partial
Seizures
 Older term ‘grand mal’

Involve the whole brain

Tonic
Generalized • Muscles stiffen
Seizures • Air escapes lungs
• Generally a LOC

Clonic
• Rapid, rhythmic jerking of arms/legs
• May be loss of bladder/bowel
control
Generalized
Seizures
Absence
Seizures
 What is the post-ictal
phase?

Post-Ictal Confused
Hard to arouse
Manifestations: Somnolent,
Phase snoring resps

May c/o headache,

sore muscles, fatigue,
depression
 Plan of Care for a Patient
Experiencing a Seizure

• Observe and document patient signs

and symptoms before, during, and
after seizure
– Pre-seizure stimuli (flashing
lights)
– Aura
– Beginning symptom(s)(lie down if
they know its coming)
– Movements
– Pupils
– Incontinence
 Plan of Care for a Patient
Experiencing a Seizure
Nursing actions during seizure for patient
safety and protection

Such as?

See chart in text

Guidelines for Seizure Care
 After Seizure Care
Maintain side-lying position

Ensure patent airway and adequate oxygenation

Safety if confused

Re-orientate

Reassure

Calm manner
 Anti-Seizure Medications –
Phenytoin

• Phenytoin (Dilantin) (po, IV)

• Class of medication?
– Anticonvulsant

• Maintenance therapy
• 100 mg tabs PO TID
• Dose adjustments no sooner
than 7-10 day intervals when
indicated
– Narrow therapeutic range
Phenytoin (Dilantin) cont

• Monitor medication levels

– 3-9 hours after dose for peak
– 30 min before next sched dose for
trough
• Adverse effects
– Visual disturbances, hirsutism,
gingival hyperplasia,
dysrhythmias, severe skin
reactions, blood dyscrasias
 Anti-Seizure Medications -
Carbamazepine
• Carbamazepine (Tegretol)
• Class of medication?
Anticonvulsant
• Route of administration? PO, IV
• Monitor levels (peak, trough)
• Adverse effects
– Dizziness, drowsiness, N + V,
blood dyscrasias, hepatotoxicity
 Goal to achieve seizure
control with minimal s/e

Important Long-term use associated

Considerations with bone loss and
osteoporosis
with
Anti-
Convulsant Decreased effectiveness of
contraceptive
Medications

Safety during not safe during

pregnancy ** pregnancy
 Other Seizure Management
Medications
• Clonazepam (Klonopin, Rivotril)
• Class of medication?
Benzodiazapine
• Route of administration? PO
• Dosage usually 0.5mg tid for seizure
prophylaxis
• Adverse effects
– Drowsiness, behavioral changes,
hepatotoxicity,
thrombocytopenia
 Patient Education

Medication Avoid seizure

Seizure diary
compliance triggers

Monitor for s/s Bloodwork as

Check otc meds
of toxicity ordered

Safety
Medic alert • Activities that require
alertness/coordination
 A medical emergency

A series of generalized
Status seizures that occur
without full recovery of
Epilepticus consciousness between
attacks

Continuous clinical or electrical

seizures lasting at least 30
minutes, even without
impairment of consciousness
 The nurse initiates ongoing
assessment and monitoring of
respiratory and cardiac
function
Status
Epilepticus
Goals of Tx
Goals of Treatment
stop the seizures
ensure adequate maintain the
as quickly as
cerebral patient in a
possible (IV
oxygenation seizure-free state
meds)
Status Epilepticus - Meds
 Febrile Seizures (childhood)

Usually occur 3m - 5y of age

Assoc with fever, but no evidence of intracranial infection or

defined cause
Usually lasts 1-10 min

Temp usually rises quickly

Average febrile temp is 40 degrees C

 Question

• What underlying
conditions or illnesses
may result in febrile
seizures?

• Are there any red flags?

 During the Seizure

• Stay CALM
• Position child how:
• Maintain airway
• Time start and end of seizure
• What else?

This Photo by Unknown Author is licensed under

CC BY-SA
 After the Seizure

• Fever management
– Pharmacologic
– Except
– Non-pharmacologic
• Medical attn if required
• Identify underlying cause
– Viral infections
– Bacterial infections
 Febrile Seizures (childhood)

A visit to the ER is
Call 911 if:
warranted if:
• Temp > 39.4°C (104F) • Febrile seizure lasts
in a child > 3 months more than five minutes
• Child stops breathing
• Temp 38°C (100.5F) in • Skin starts to turn blue
an infant < 3 months • Fever > than 41°C
(105.8°F), a condition
• Child's first seizure called hyperpyrexia
 True or False

• If you have a seizure, it

means you have
epilepsy. T/F

This Photo by Unknown Author is licensed under CC BY-SA-NC

Headaches

• Also called cephalgia

• One of the most
common physical
complaints
• May cause significant
discomfort and impact
quality of life. How?
 *Red Flags*

• Abrupt, severe headache (Thunderclap)

• *** First or worst headache of your life***

• Headache with fever, stiff neck, mental

confusion, seizures, double vision, weakness,
numbness or speaking difficulties

• Severe headache after a head injury, especially if

the headache gets worse
Imaging
When is imaging
required related to
headaches?
If underlying cause is
expected

This Photo by Unknown Author is licensed under CC BY-SA-NC

 Primary Headache Disorder
No known organic cause

Not due to another condition

Examples of primary headaches:

• Migraine
• Cluster
• Tension
Assessment / Headache History
Detailed Description
Onset
• When did it start
• Progression (worsening)
• Duration
• Frequency ie days per month with headache

Location
• Unilateral or bilateral
• Area(s) affected
• Associated neck pain
Assessment / Headache History
Detailed Description
Associated symptoms
• nausea, vomiting
• Photophobia
• Phonophobia

Precipitating factors
• What was pt doing when headache started?
• Stress, posture, cough, exertion, straining, neck
movements, jaw pain, etc.
• Hx head or neck trauma
Assessment / Headache History
Detailed Description
Co-existing conditions

• Insomnia, Anxiety/depression,
hypertension/cardiovascular disease, asthma,

Medication history and use

• Response/side effects to past treatments

(preventative and abortive)
 Migraine Headache

• Criteria outlined in this document

https://ichd-3.org/1-migraine/1-1-
migraine-without-aura/
• Migraine headaches without aura
• Key info:
– Unilateral, pulsing quality, mod-
severe, 4-72 hrs, worse with activity,
N and/or V, photophobia /
phonophobia
 Migraine Headache Aura

• Same features as migraine without

aura but with:
• Fully reversible visual symptoms
– Flickering lights, spots, lines, loss of
vision
• Fully reversible sensory symptoms
– Pins and needles, numbness
• Fully reversible speech disturbance
– Ie dysphagia
• Preceed headache and last >5 min
<60min
Migraine Aura
4 Phases of Migraine
 Migraine Management

• Comprehensive migraine therapy

includes:
– acute and prophylactic
medications
– management of lifestyle factors
and triggers
– migraine self-management
strategies
 Pharmacologic Management

• Pharmacologic management
can be abortive or
preventative (prophylactic)

• Step-wise approach

• Opioids not indicated

 Pharmacologic Management
Abortive Treatment

• Abortive medication taken at first sign of

attack

• First line medications (acute) NSAIDs

(including ASA), acetaminophen
– Dose appropriately

• Metoclopramide 10mg IV
– Monitor for EPS (tongue thrusting,
involuntary movements)
 • Sumatriptan (ImitrexTM) (oral 25, 50,
100mg)
• Rizatriptan (MaxaltTM)
Abortive • Eletriptan (RelpaxTM)

Medications • Formulations?
- Triptans • Contraindications?
– Ischemic heart disease
• Teaching points?
– Take at first symptoms
 Preventative or Prophylactic
Medications

• Used when acute medications not effective

• Can result in 50% fewer migraines
• Take 6-8 weeks to take effect
• Most commonly used prophylactic meds for
migraines?
• Beta-blockers: propanolol
– Class: betablocker
– Name, dose range: 20mg
– Cautions: monitor HR and BP, hx of asthma
– Pt teaching: take as prescribed, don’t stop
suddenly
Non-Pharmacologic/Self-Management
Self-monitoring to identify triggers.
Examples?
Caffeine Headache diary
Alcohol
Chocolate

Quiet, dark room Relaxation/stress management

Biofeedback, cognitive behavioural

Sleep Hygiene
therapy, acupuncture
 Other Headaches

Cluster Tension Temporal

headaches headaches Arteritis
• Severe form of • Bilateral, non- • Inflammation of
vascular pulsating cranial arteries
headache • Mild to moderate • Older adults >70yr
• More common in intensity • Elevation in the ESR
men and C-reactive
protein (CRP) levels
Secondary Headache Disorder

Secondary headache is a symptom with an organic

cause such as _____________?

*** Must be ruled out before assumption can be

made that it is a primary headache disorder ***

Most headaches do not indicate serious disease,

but persistent headaches require investigation
(detailed history, physical, neuro exam)
Meningitis
 Meningitis

• Inflammation of the
protective lining
(meninges) of the brain
and spinal cord

• Medical emergency
 Bacterial Meningitis

• Septic (bacterial) meningitis

– Bacteria reach meninges via bloodstream
– Complication of sinusitis, endocarditis,
pneumonia, etc
– Neisseria meningitidis, H. influenzae, Strept
pneumoniae, group B streptococcus most
common

• Or direct contact (ie open head injury, invasive

procedures)
 Meningitis Risk Factors

Age (infants at
Smoking URTI, OM
highest risk)

Immunodeficiency
(HIV, auto-immune Travel to high-risk
Community settings
disorders, diabetes, areas
ETOH, etc)
 Clinical Manifestations

• Headache
• Fever
• Nuchal rigidity
• Photophobia
• Disorientation
• Seizures
• Positive Kernig and Brudzinski signs
Kernig and Brudzinski signs
 Diagnostic Tests
• Lumbar puncture
– Gram stain and culture of CSF
• CBC
– What specific components?
• WBC
• Blood cultures
– 2 different sites
• CT scan This Photo by Unknown Author is
licensed under CC BY-SA
• What else?
– Past medical Hx for risk factors
 Bacterial Meningitis
Medical Management

• Aggressive tx with antibx that cross

blood-brain barrier
– Broad spectrum, multiple therapy
• Corticosteroid therapy
• Fluids to manage dehydration/shock
• Seizures management
• Supportive tx
 Nursing Management
• Neuro and vital signs
• SaO2, ABGs
– May require mechanical ventilation
• Bloodwork
– What and why?
– CBC, electrolytes, liver+kidney
function, lactate
• Protect from injury 20 to altered
mental status
• Support patient, family
• Prognosis? Not good
 Droplet Precautions
• Oral and nasal discharge considered infectious
• Droplet precautions until 24 hrs after initiation
of antibx therapy
• Hand hygiene
• Preferred private room/BR
• Gloves, gown, mask, eye/face shield

• Review pages 2292-2293

 Aseptic Meningitis

Viral • HSV 2, HIV, varicella,

Fungal • Syphilis, Lyme disease, TB

Parasitic
causes

Secondary • Lymphoma, leukemia, etc