Neurological Disorders

NEUROLOGICAL DISORDERS

·         Epilepsy

·         Uncouncious Status

1. Epilepsy

Epilepsy is a tendency to have recurrent seizures, which results from disturbances in the normal electrical activity of the brain.

The human brain is a unique computer, which works for all 24 hours. It is built up of billions of nerve cells called neuron. The neuron has electrical activity and this is transmitted through the axons and dendrites. These electrical impulses are transmitted from one neuron to another through the chemical messengers called neurotransmitters, which are present in the synapse If a group of nerve cells start sending these impulses excessively, it results into epileptic attacks.

Causes

Epilepsy is a symptom of many diseases. Just as headache, it is a symptom, which has a number of causes. Epilepsy can be caused by a number of illness in the brain.

Idiopathic

·           No demonstrable cause  

Symptomatic

·           Prenatal injuries

·           Low sugar, sodium or calcium

·           Developmental defect of the brain

·           Cerebral infections like meningitis, encephalitis

·           Cerebral injuries

·           Cerebral tumors

·           Cerebro vascular attack

·           Cysticercus and tuberculomas

Signs & Symptoms

·            Unconsciousness

·            Rigid body

·            Jerking movements of arms and legs

·            Clenching of teeth

·            Grunting noises

·            Confusion (one or two minutes)

Partial seizures

In partial seizures the abnormal electrical discharges occur in a localized area in the brain. Hence the symptoms depend upon the area of brain involved, motor or sensory.

Simple partial seizures

Simple partial seizures do not affect consciousness. Symptoms may include rhythmic movements of the contralateral face, arm or leg and possibly hallucinations involving smell, sight or hearing or feelings of fear and panic or euphoria.

Complex partial seizures

Complex partial seizures are the most common type of seizure in adults, commonly lasting less than three minutes and associated with impairment in the consciousness they become complex partial seizures.

Generalised seizures

Generalized seizures affect the whole cortex with the patient’s level of consciousness usually being impaired; there is often no aura or warning. Generalized seizures have varying characteristics.

·            Typical absence seizures are distinguished by a transient loss of consciousness and awareness of the environment with a vacant appearance, which lasts just a few seconds

·            Atypical absence seizures resemble typical absence seizures but last longer and are often associated with minor automatism

·            Myoclonic seizures are classified by sudden muscle contractions of specific muscle groups with no loss of consciousness

·            Tonic-clonic seizures involve bilateral extension of limbs followed by synchronous jerking movements. There is often acry before the seizure, a fall to the ground followed by incontinence, tongue biting, foaming at the mouth and loss of consciousness. There is a post-ictal phase and when patients wake they have muscle tenderness, transient confusion and exhaustion

·            Atonic seizures cause loss of muscle tone and a fall to the ground, often resulting in injury; it may be so brief that the patient is unaware of the loss of consciousness

Signs & Symptoms

·            Headache, fainting attack

·            Muscle spasms

·            Black out or fall jerky movement  

·            Incontinence of bladder or bowel  

·            Tongue bite, breathing difficulty

Investigations

·            EEG

·            CT-Brain

·            MRI-Brain

Management

Medical Management

Drugs

·           Carbamazepine

·           Phenytoin

·           Valporic acid

Surgical Management

·            Reserve and palliative operations (temporal lobotomy, extra temporal resection, corpus colostomy, hemisperectomy)

Nursing Management

·            Maintain a patient airway until patient is fully awake after a seizure

·            Provide oxygen during the seizure if color change occurs

·            Stress the importance of taking medication regularly

·            Provide a safe environment by padding side rails and removing clutter

·            Place a bed in a low position and place a patient on side during a seizure to prevent aspiration

·            Do not restrain the patient during a seizure

·            Do not put anything in the patient mouth during a seizure

·            Protect the patient’s head during a seizure.

·            Stay with a patient who is ambulating or who is in a confused state during seizure

·            Provide a helmet to the patient who falls during seizure

·            Consult with social worker for community resources for vocational rehabilitation, counsellors and support groups

·            Teach stress reduction techniques that will fit into a patient lifestyle

·            Answer questions related to use of computerized video EEG monitoring and surgery for epilepsy management

Complication

·           Status epileptics

·            Injuries due to falls

2.  Unconscious Status

Unconsciousness is a condition in which there is depression of cerebral function ranging from stupor to coma.

Coma may be defined as no eye opening on stimulation, absence of comprehensible speech, a failure to obey commands.

Unconsciousness is a lack of awareness of one’s environment and the inability to respond to external stimuli.

Therefore, observe the patient’s condition and prevent any complications.

Causes

·           Head injuries

·           Meningitis, encephalitis

·           Diabetes mellitus

·           Renal failure

·            Poisonous drugs (stomach wash, refer practicals)

·           Asphaxia

·           Epilepsy

Diagnosis

Assess the patient’s level of consciousness by Glasgow coma scale.

·           Responses to command

·           Eye opening

·           Verbal responses

·           Motor responses

Glasgow Coma Scale Assessment

Interpretation

·           Best score

·           Worst Score

·           7 or less generally indicates coma (Changes from baseline are most important)

Nursing Management

Maintenance of effective airway:

·           An adequate airway must be maintained at all times.

·            It must be necessary to hold the patients jaw forward or place the patient in the lateral position to prevent the tongue obstructing airway by falling back.

·           Loosen the garments to allow free movements of the chest and abdomen.

·           Frequent suction is required to prevent the pooling of secretion in the patients pharynx.

·           If necessary insert oral airway for easy breathing.

Maintenance of fluid & electrolyte balance and nutrition:

·           The diet must contain an adequate supply of all nutrients required for life. Nutrition may be supplied by intravenous fluids or gastric tube feeding. (refer practicals)

·           Administer prescribed intravenous fluids with electrolytes and vitamins (refer practicals).

·           Maintain Intake and output chart accurately.

·           Monitor vital signs and record.

Maintenance of personal hygiene and care of pressure areas including prevention of foot drop:

·           Sponging is performed as frequently as necessary

·           Keep the skin dry, clean and free of moisture to prevent bed sore.

·           Apply back care every 4th hourly and 2nd hourly position changing to relieve pressure on pressure areas.

·           Clip the nails

·            Range of motion exercises atleast 4 times a day.

·           Cleanse the mouth with the prescribed solution every 2nd hourly and apply emollients to prevent parotitis.

·           Irrigate the eye with sterile prescribed solution to remove discharge and debris.

·           Clean the ear with swab and dry carefully, especially behind the ears.

·           The bed linen must be kept wrinkle free and dry.

·           Side railing on both sides are helpful to protect the patient.

·           The feet should be kept at right angles to the legs with help of pillow or sand bags to prevent foot drop.

Promoting elimination:

·           If the patient is observed for any sign of urinary incontinency, retention and constipation, report to the physician.

·           If the patient has incontinence of urine – provide bedpan or catheterization can be done according to Doctor’s order to record the accurate output. (refer practicals).

·           If the patient has retention of urine, apply gentle pressure over the bladder region. It will help in partially emptying the bladder.

·           If the patient is constipated, a glycerine suppository or enema is advised according to Doctor’s prescription.

·           Perineal care, vaginal douch, catheter care to be provided (refer practicals).

·            Palpate the abdomen for distension.

·            Auscultate bowel sounds.

Family education:

·           Develop an interpersonal relationship with the family.

·           Provide frequent update information on patient condition.

·           Involve the relatives in routine care.

·           Provide comfortable physical environment.

·            Teach family to report any unusual symptoms.