Utilizing critical thinking and the nursing process, the student is expected to:
Examine the etiology and pathophysiology and risk factors for the following disorders:
- Headache: cluster, migraine, tension
- Seizures: partial (simple, Jacksonian, automatism), generalized (absence, tonic-clonic, and status epilepticus)
- Dementia vs delirium (causes of each)
- Alzheimer's disease: familial and sporadic
the patient with neurosensory problems
- Glascow coma scale
- Analysis of any symptoms
- Related History
- Physical exam: mental status exam, neuro checks, cranial nerve assessment
- Examine the signs and symptoms of the disorders:
Examine the complications of the neurosensory disorders.
Examine the following diagnostic test including the purpose, nursing care, normal values, and interpretation of abnormal values.
- Differentiate between the classifications of seizures
- types of headaches (table 59-1)
- stages of Alzheimer's Disease
Select relevant nursing diagnosis that address physical, psychosocial, and learning needs.
- Electroencephalogram or EEG
- CT scan
- Magnetic Resonance Imaging or MRI
- cerebral angiogram
- Blood tests: serum glucose, BUN, Vit b, B6, B12, thyroid function tests, liver function,
- IHS criteria, headache diary
Plan goals to assist the client toward health promotion, maintenance, and or restoration.
Select nursing interventions to meet goals:
- Ineffective breathing pattern r/t neuromuscular impairment secondary to prolonged tonic phase of seizure or during postictal period
- Risk for injury r/t seizure activity and subsequent impaired physical mobility
- Ineffective coping r/t perceived loss of control and denial of diagnosis of seizures
- Ineffective therapeutic regimen management r/t to lack of knowledge about management of seizure disorder
- Disturbed thought processes r/t effects of dementia
- Self-care deficit r/t memory deficity & neuromuschular impairment
- HRF Injury r/t impaired judgement, gait instability, weakness, sensory perceptual alteration
- Wandering r/t disease process (see sundowning pg 1573)
- Acute pain
- Ineffective coping
Evaluate goals and explain possible changes in the nursing care plan.
Discuss associated issues and trends and legal/ethical consideration.
- Antiseizure: Dilantin (phenytoin), Depakene (valproic acid), Tegretol (carbamazepine) Topamax (topiramate), Phenobarbital Table 59-3
- benzodiazepines: Valium, Ativan
- cholinesterase inhibitors: Aricept (donepezil), Namenda (memantine),
- antipsychotics: risperidone (Risperdal), olanzapine (Zyprexa)
- Headaches (distinguish between prophylactic and symptomatic treatment)
- beta blocker
- triptans: sumatriptan (Imitrex)
- antiseizure: topiramate (Topamax)
- calcium channel blocker: verapamil (Isoptin)
- serotonin antagonist: methysergide (Sansert)
- Patient teaching:
- Teaching related to medications, factors that can trigger a headache, diet, stress reduction, exercise, contact health provider
- identify ways to promote health with the disorder
- Family teaching for a patient with seizures
- Seizure precaustions
- Nursing Implementation for Alzheimer's, pg 1570-1575
- Collaborative interventions: Identify other health care team members involved in the care of the patient with the disorder
- seizure precautions
- Managing confusion and anxiety in Alzheimer's disease
- communication with the Alzheimer's patient.
- Consider efficient use of human and material resources.
||Review module objectives.
- Lewis, S., Heitkemper, M., Dirksen, S., O'Brien, P., and Bucher, l. (2007). Medical Surgical Nursing: Assessment and Management of Clinical Problems, St. Louis: Mosby,Neurological Assessment & glasgow coma scale pp.1476-1477 & headache - pp. 1527-1532; seizures
- pp. 1533-1541; alzheimer's
disease - pp. 1561-1579.
Complete module exercises:
Resources (not required):
- O'Brien, P.Lewis, S., Heitkemper, M., Dirksen, S.,and Bucher, l. (2007)Study Guide: Medical Surgical Nursing. Chapter 59: questions: 1-6,8-15, Chapter 60: 1-7,9-18, alzheimers case study
- Alzheimer's Disease Education
and Referral Center
- Another Alzheimer's site
I like this site because it gives 7 stages which I find more helpful
in tracking progression than the more simple 3 stage approach.
In reality there is a lot of variation in symptoms at any stage,
depending on what part of the brain is affected first.
- Powerpoint presentation on diagnosis of Alzheimer's Disease.
module objectives and check for knowledge gaps.
the module quiz in Blackboard.