Pathophysiology of Epileptic Person with Traumatic Brain Injury - Case Study Example

Epileptic case study and management Name: Unit name: Course: Supervisor: Date of submission: Pathophysiology of epileptic person with TBI Ms. Bilbo is likely to be experiencing one or all of the following changes. Leitgeb, Mauritz, Brazinova, Janciak, Majdan, Wilbacher et al., (2012).Seizures; this is common following brain injury on an epileptic person. It mostly occurs either as a secondary generalized focal or focal motor. The same studies show that this happens often in the first week following head trauma for those who are not actually hurt by an external object seizure prevalence is about 5% patients. The possibility of developing seizure is more likely to persons who have cortical laceration. Seizures are likely to reoccur after 6-18 (later onset) months and this is related to the brain having blood products. However, for Ms. Bilbo subdural hematoma has been experienced following TBI which is still not an extraordinary case since he suffers from epileptic. Subdural hematoma’s results when flow disruption of the veins connecting the venous dural sinuses and the brain occurs. This hemorrhagic effect arises following angular forces, forcing the dura move according to its mother anchorage; the skull, leaving behind the cerebral hemisphere. Shearing of bridging veins occurs; in addition, stretching is experienced on the veins bridging the enlarged space of subdural space. Symptoms and signs of hematoma are experienced after sometimes following the impact; usually a day to several days. This is because; the bleeding occurring from the vein is usually at a very low pressure. Therefore, the blood collects at a slow pace. Following the slow hematoma formation, brain shift occurs and distortion of brain stem is experienced. There are episodes of chronic headache, cognitive function difficulty and consciousness effect arising from mild depression. Wax and wane of subdural hematoma occurs after hours or days in patients following these effects, there are possibilities of focal cortical dysfunction which varies depending on the affected region of the brain, confusion, depression of consciousness and headache. Seizures are common to the brain following the blood products close to the brain Badri, Chen, Barber, Temkin, Dikmen, Chesnut et al., (2012). Possibilities of respiratory patterns disruptions are also high among TBI patients something that Ms. Bilbo might be going through. This occurs as a result of compression of the midbrain, and there is shift of progresses of normal breathing to hyperventilation on the central neurogenic parameters to apnea following compression of the medulla. The pupil on the other hand moves to mid-position. It is not able to respond to light (pupillary response) due to compression of the descending sympathetic pathway and the nucleus of the third cranial nerve arising from compression in the upper midbrain. Increased transtentorial herniation provides no further pupil changes as well as descending compression in the brain stem Leitgeb et al., (2012). According to Robertson & Knight (2008) A person suffering from consciousness arising from depression as it is likely to be happening to Ms. Bilbo, disinhibited oculocephalic reflex is common. This can be examined by turning the patients head quickly. However; this exam procedure should be exempted in patients feared to have neck injury; caloric testing is advocated in such a case. Disinhibited response is experienced in patients with functioning brain stem, but who are unconscious. The eyes of the patient are immobile they are kind of fixed to a particular fictional point and do not follow the turning of the head. In fact, they move in the opposite head direction. Eyes do not follow the head movement in cases where the reflex is deemed to be absent and remain fixed at a particular point. Third-nerve compression (upper midbrain) causes adduction movement disappearance. Consequently, there is occurrence of the abduction movements following compression progression which attacks the sixth-nerve (pons). If the sixth-nerve stretches against petrous bone edge there is loss of abduction. Leitgeb et al., (2012) Compressed midbrain affects motor response as well. As a result, there are decerebrate posturing tone progression and impact on normal motor strength. Decerebrate posturing is portrayed by either noxious stimulation such as tickling the nose or spontaneously carrying an internal rotation of leg and arm extensions. The reflex is generated by vestibular nuclei housed in the brain stem (caudal). If a patient has decerebrate posturing, it is a good indicator of a compromised rostral brain stem. Similar to decerebrate posturing, is decorticate posturing. However, for decorticate posturing internal rotation is done with arm flexion and leg extension spontaneously. This posturing occurs following the interruption activity of the impulses of descending cortical motor. The interruptions should only be realized above midbrain level without affecting vestibulospinal and rubrospinal motor systems. The presence of epileptic in Ms. Bilbo is accounted for increased neuronal excitability and interictal-ictal transition Topal, Hakyemez & Erdogan (2008). The intrinsic and synaptic functions of the neurons is altered; a mechanism arising from hyperexcitability. This happens because there is gamma-amino butyric acid and glutamate imbalance in the neurotransmitter systems. In addition, opioid peptides and catecholaminergic neurotransmitter systems are contributing factors in epileptogesis. Ms. Bilbo’s nursing interventions and evaluation Epilepsy is a condition arising from unknown cause presented with recurring seizures. Seizure is a unique event that is presented with abnormal brain electrons discharge which is excessive or synchronous and sudden. Consciousness level, sensory function and motor alteration are other reactions likely to accompany these sequences. Nursing care is vital in regards to risk management, tests, diagnosis and epileptic symptoms assessment Hosking & Sander (2006). Role of epilepsy nurses General overview Epileptic patients do receive their chronic treatment and management from a primary health care provider, usually not from a neurologist. It is, therefore, importance for primary health care givers to clearly understand diagnoses and treatment in a broad and in-depth manner regarding epilepsy. Epilepsy nurses are professionals in the modern world well equipped with knowledge and do provide education and coordinated care to epileptic persons regarding the complexity nature of the condition. During management and intervention to Ms. Bilbo, nurses will be actively involved in giving diagnoses advises and reassuring the patient Courtenay & Carey (2008). They will also be involved in examining and informing the patient on antiepileptic drug changes. In addition, the nurses should be able to give the client accurate information, to perform an audit which comprises the full and comprehensive profile of the client so that it may help in devising plans of treatment, goals and improve on care practices. The major reason for incorporating nursing intervention in Ms. Bilbo epileptic condition management is to ensure she does not end up into psychological stress and that she achieves physiological functioning Hosking & Sander (2006). Justification of epileptic management People with developmental disabilities experience disorders of seizures. The basic objective on seizure management is to reduce or eliminate disorders occurring following seizures. To ensure maximum seizure control there is need for individual cooperation with the nurses. Treatment order, seizure type classification and seizure medical diagnoses can only be carried by a medical consultant or primary care prescriber. To ensure the best seizure treatment and management is provided ICSES (International Classification System of Epileptic Seizures) guidelines need to be followed or facility epileptic protocol by the nurses McElroy-Cox (2009). However, Courtenay & Carey (2008) it should be noted that insufficient or lack of history, confusing clinical presentations and communication deficits are liable for improper classification and diagnosis. Baustista, Glen, Shetty & Wludyka (2009) to ensure reliable diagnosis is achieved collaborative information from observers should be relied on by the health care givers. In addition, there should be adequate and accurate seizure descriptions reporting and recording for optimum management of seizure. It is of much importance to train the observers and epileptic care givers as well as supportive staff on how to observe, record seizure activity when they arise, manage and protect Ms. Bilbo in the event of seizure and after. The nursing input will be required all through Ms. Bilbo’s management that is; from initial intervention, nursing assessment, diagnostic examinations, planning, implementation and evaluation of seizure occurrence in Ms. Bilbo Hosking & Sander (2006). Initial intervention The best intervention occurs during seizure episode. During this time the nurse should assess and put down all the activity observed and reported by other people around the patient Courtenay & Carey (2008). This assessment need to include cardio-pulmonary risk level of the client. If the nurses find it important notifying a doctor or other medical consultant this should also be added into the nursing notes Balabanov & Rossi (2008). The nurse ought to continue following the Prolonged Seizure Activity Guidelines, writing down all the information observed from the client and reported, the actions taken and the client’s treatment response for reference purposes and drug evaluation Hansen, Campbell & Sullivan (2009). Nursing assessment The nurses attending Ms. Bilbo during events of seizure should record exactly what happened during active seizure (ictal phase) Ciechanowski, Chayton, Miller, Fraser, Russo, Unutzer & Gilliam (2010). Incase where the nurse is not present during seizure should gather all the information and record from the observers who did witness the seize episode. Postictal seizure phase should be monitored carefully and all reactions and activity recorded. If the nurses finds it worthy recommending for medical consultant this should as well be put in writing alongside nursing notes. This will help in deciding on drug prognosis for Ms. Bilbo Walker, Obolensky, Dini & Thompson (2010). Diagnostic reasoning Any unique happening from the patient need to be noted as they will help in deciding what is the best information to report or address. Such detail may include: levels of serum anticonvulsant recently analyse, results and reports of EEG, reports of neurological consultants if any and required follow-up intervention, injuries or complications seizure related, seizure characteristics, type, last episode (date and time) and the frequency, past history and the ongoing medications Taylor, Sander, Taylor & Baker (2011) and Benbadis (2007) This will ensure any review is in order for Ms. Bilbo. Planning The nurse should put down all the strategies advisable for seizure management. This will include: Ms. Bilbo potential or actual health problems, Ms. Bilbo’s risk factors which should be added to her Single Plan and health assessment report. Anticonvulsant Levetiracetam effects and psychotropic medication (clonazepam) should be assessed regarding the seizure status and information put into writing. This will help during Ms. Bilbo’s Plan on Psychotropic Drug Review Hansen, Campbell & Sullivan (2009). In addition, the Single Plan health section should also include seizure activity trends, associated and precipitating factors, frequency and type of seizure. The nurse should include the actual and or potential side effects likely to arise from anticonvulsant drugs in the section of the Single Plan health report. The nurse should be involved in training Ms. Bilbo’s care givers. The training program should cover seizure related issues, safety seizure issues, documentation, management and observation this will ensure what happens during seizure on Ms. Bilbo is clearly noted. The carers can take necessary action to assist Ms. Bilbo in absentia of the nurse. The nurses should record all activity plans that will aid in making Ms. Bilbo become much independent in Single Plan Baustista, Glen, Shetty & Wludyka (2009). Such activity will include recommendations geared towards secondary complication and injuries prevention. Implementation All initial plans need to be put into action and proposed intervention documented. Such will include: carrying out diagnostic procedures, treatment and drug order followed to the latter. The nurse should comment whether the advised diagnostic procedures were carried out and completed as advised and if note possibly why. This information should be among nursing notes regarding Ms. Bilbo. All the practices recommended to prevent Ms. Bilbo from injury need to commence immediately as prescribed Courtenay & Carey (2008). The nurse should record all activities during seizure in Ms. Bilbo’s record. Periodic review should also be documented to find out how the changes and trends of seizure in Ms. Bilbo are occurring. Ms. Bilbo’s seizure evaluation Seizure is not a one time treatment and diagnosis. Therefore, the nurse attending Ms. Bilbo will have to monitor how the client is doing following seizure management program and give recommendations following changes experienced or observed during the management progress Barling, Ettinger, Friel, Gilliam, Harden, Hermannet al., (2008). Frequency and type of seizure should be put down in writing and report given Ciechanowski, Chayton, Miller, Fraser, Russo, Unutzer & Gilliam (2010). For accuracy and completeness the record of seizure need to be reviewed regularly. Post-itcal care for a patient Post-itcal is the happenings which follows seizure episodes. In a situation where there is no seizure experience the patient may resume normal physiological and psychological functioning as usual. However, Benbadis (2009) partial or major motor complexes in a patient may make the client appear disoriented, confused or dazed. During this stage, the nurse should record all the following conditions, duration and frequency. Assessment should be carried on an epileptic patient until he returns to her normal state. The assessments include: decreased gag reflex, severity, location, duration and character of headache, bowel and bladder incontinence, injury (trauma in the mouth, lacerations, fractures, burns and bruises), residual deficit encompassing distracted sleep patterns, body parts paralysis or weakness, poor coordination, disturbance of language, confusion and behavior change. The nurse should allow the patient to sleep and reorient on awakening to reduce anxiety and regain self control hence achieve good sleep Kucukarslan, Reeves & McAuley (2008). In addition, it is the duty of the nurse to carry out a post seizure exam Sperling, Schilling, Glosser, Tracy, & Asadi-Pooya (2008). This encompasses examining possible triggering factors, presence of other illnesses, reviewing of drugs the patient is using and dosages, finding out the number of seizures the patient has experienced and the activities the client was doing before seizure occurred. Visual field defects, reflex asymmetry, anesthesia, aphasia and hemiparesis should also be examined for any neurological postictal deficit and the period taken to resolve the defect; usually this is within 24 hours. For effective analysis and management of the internal environment after seizure, the nurse should inform the client importance of EEG repetition even if it was performed during admission Benbadis, LaFrance, Papandonatos, Korabathina, Lin & Kraemer (2009). That is; it is geared towards evaluating the abnormalities in seizure (type, seizure syndrome, pseudoseizuires diagnoses). The information will also help in case there is need for pre-surgical work up and give directions in deciding the best drugs for the patient. The nurse should also educate the client factors to put into consideration in regards to physical activity, diet and general health. In all the stages of seizure development and management the nurse should reassure the client so as to gain conscious fast and be on feet with a lot of strength Weaver (2011). References Badri S., Chen J., Barber J.,Temkin N.R., Dikmen S.S., Chesnut R.M. et al., (2012). Mortality and long-term functional outcome associated with in cranial pressure after traumatic brain injury. Intensive Care Med 38(11):1800-1809 Balabanov A. & Rossi M.A. (2008). Epilepsy surgery and vagal nerve stimulation what all neurologists should know. Semin Neurol 28(3):355-363 Baustista R.E., Glen E.T., Shetty N.K. & Wludyka P. (2009). The association between health literacy and outcomes of care among epilepsy patients. Seizure 18(6):400-404 Barling J.J., Ettinger A.B., Friel P., Gilliam F.G., Harden C.L., Hermann B. et al., (2008). Consensus statement: The evaluation and treatment of people with epilepsy and effective disorders. Epilepsy and behavior. Suppl.13 (1):S1-S29 Benbadis S.R. (2009). Localization-related epilepsy: causes and clinical features. UptoDate Benbadis S.R., LaFrance W.C., Papandonatos G.D., Korabathina K., Lin K. & Kraemer H.C. (2009). Interrater reliability of EEG-video monitoring. Neurology 73(11):843-846 Benbadis S.R. (2007). Differential diagnosis of epilepsy. Continuum Lifelong Learning Neurol. 13(4):48-70 Ciechanowski P., Chayton N., Miller J., Fraser R., Russo J.,Unutzer J & Gilliam F. (2010). Depression treatment for individuals with epilepsy: A randomized controlled trial. Epilepsy and Behavior 19(3):225-231 Courtenay M. & Carey N. (2008). Nurse independent prescribing and nurse supplementary prescribing practice: national survey. J Adv Nurs 61:291-299 Hansen R.N., Campbell J.D. & Sullivan S.D. (2009). Association between antiepileptic drug switching and epilepsy related events. Epilepsy Behavior 15:481-485 Hosking P.G. & Sander J.W. (2006). Nurse prescribing and the management of epilepsy. Epilepsia. 47:669-671 Kucukarslan S., Reeves A.L. & McAuley J.W. (2008). Patient-perceived risk associated with epilepsy and its medication treatment. Epilepsy and behavior 13(3):449-453 Leitgeb J., Mauritz W., Brazinova A., Janciak I.,Majdan M., Wilbacher I et al., (2012). Outcome after severe brain trauma due to acute subdural hematoma. Journal of Neurosurgicery 117(2):324-333 McElroy-Cox C. (2009). Caring for patients with epilepsy. Nurse pract. 32(10):34-40 Robertson R.H.&Knight R.G.(2008). Evaluation of social problem solving after traumatic brain injury. Neuropsychological Rehabilitation 18(2):236-250 Sperling M.R., Schilling C.A., Glosser D., Tracy J.I. & Asadi-Pooya A. A. (2008). Self-perception of seizure precipitants and their relation to anxiety level, depression and health locus of control in epilepsy. Seizure. 17(4):302-307 Taylor R.S., Sander J.W., Taylor R.J. & Baker G.A. (2011). Predictors of health-related quality of life and costs in adults with epilepsy: A systematic review. Epilepsia. 52(12):2168-2180 Topal N.B., Hakyemez B. & Erdogan C. (2008). MR imaging in the detection of diffuse axonal injury with mild traumatic brain injury. Neurol Res Walker E.R., Obolensky N., Dini S. & Thompson N.J. (2010). Formative and process evaluation of a cognitive behavioral therapy and mindfulness intervention for people with epilepsy and depression. Epilepsy Behavior. 19(3):239-246 Weaver V.H. (2011). High fidelity patient simulation in nursing education: An integrative review. Nursing Education Perspectives 32(1):37-40 Read More