Management of patient with Neurologic Dysfunction

 Chapter outline:
1-altered level of consciousness 2-increased intracranial pressure (ICP)
3-neurosurgical procedures 4-seizures 5-headaches
 Some of these disorder may be symptoms of dysfunction in another body
system,disruption of the neurologic system. OR “idiopathic,”
optimal function depends on:
1. neurologic system relies on its structural integrity )‫يكون الجهاز العصبي سليم(مش متضرر‬
2. neurologic system relies on the body’s ability to maintain a homeostatic environment

Some conditions can be treated and

The goals are to achieve as high a
reversed; others result in
level of function as possible and to
enhance the quality of life for the
permanent neurologic deficits and
disabilities
patient with neurologic impairment
‫مش حفظ االشكال‬

1-ALTERED LEVEL OF CONSCIOUSNESS (LOC)

 (LOC):is apparent in the patient who is not oriented, does not follow commands, or needs
persistent stimuli to achieve a state of alertness ‫مهم‬
 Coma: is a clinical state of unarousable (‫ )ما بصحى‬unresponsiveness (‫ )ما بستجيب‬in which
there are no purposeful responses to internal or external stimuli
Category of coma: ‫مهمات كل فصل بيجو‬
1. Akinetic mutism: is a state of unresponsiveness to the environment in which the patient
makes no voluntary movement, but sometimes opens the eyes.
2. Persistent vegetative state: is a condition in which the unresponsive patient resumes sleep–
wake cycles after coma but is devoid of cognitive or affective mental function.
3. Locked-in syndrome :results from a lesion affecting the pons and results in paralysis and the
inability to speak, but vertical eye movements and lid elevation remain intact and are used
to indicate responsiveness
4. Minimally conscious state: the patient has inconsistent but reproducible signs of awareness.
Pt. cannot communicate thoughts or feelings
The level of responsiveness and consciousness is the most important indicator of the
patient’s condition.
 Pathophysiology:
 Altered LOC is not a disorder itself; rather, it is a result of multiple pathophysiologic phenomena.
 The cause may be
1. neurologic (head injury, stroke),
2. toxicologic (drug overdose alcohol intoxication)‫)(سكران طينه‬
3. metabolic (hepatic or renal failure, diabetic ketoacidosis ) ‫ليش؟‬.

Clinical Manifestations:
Alterations in LOC occur along a continuum, and the clinical manifestations depend on where the
patient is on this continuum

initial alterations in LOC may be reflected by subtle behavioral changes, such as restlessness or
increased anxiety. ‫بصير يعمل تصرفات غريبه‬ A score of 3 indicates severe impairment
of neurologic function, brain death, or
 in case of decreased LOC: Slow pupil response to light pharmacologic inhibition of the
 in case of coma: no pupil response(fixed)

Glasgow Coma
neurologic response.
Patients in coma don’t respond to voice or command A score of 15 indicates that the

Assessment and Diagnostic Findings: patient is fully responsive

 The patient with an altered LOC is at risk for alterations in every body system.‫ليه‬
 A complete assessment is performed, with particular attention to the neurologic system.
 Evaluation of mental status, cranial nerve function, cerebellar function (balance and
coordination), reflexes, and motor and sensory function.
 Glasgow Coma Scale: ) eye opening, verbal response, and motor response(
 To determine the cause of unconsciousness: CT, MRI, EEG, positron emission tomography (PET),
single-photo emission computed tomography (SPECT) ‫فحوصات الشابتر االول‬
 Laboratory tests: blood glucose, electrolytes, serum ammonia, LFT, BUN, serum osmolarity, , PT,
PTT, serum ketones, alcohol and drug concentration . ABGs.
 Medical Management ABC
1. obtain and maintain a patent airway , intubation and mechanical ventilation ‫اهم اشي‬
2. circulatory status (blood pressure, heart rate) is monitored
3. Nutritional therapy
4. IV access for fluid and medication
5. Neurologic care
 patient’s orientation:
NURSING PROCESS:
1. time
 Assessment: 2. place,
1. Assess patient’s verbal response 3. person
2. Assess patient’s alertness ‫زي اقرصه شوفه بستجيب‬
3. Assess Patient’s motor response ‫تاكد انه بحرك اطرافه االربعه بنفس القوة او اذا بقدرش يحرك اشي‬
4. Assess respiratory status, eye signs, reflexes
5. Assess body function (circulation, respiration, elimination, fluid and electrolyte balance)
 Nursing Diagnoses:
1. Ineffective airway clearance
2. Deficit fluid volume Collaborative Problems
3. Ineffective thermoregulation
4. Risk for infection
‫مهم‬
5. Risk for imbalanced nutrition: less than body requirement
6. Impaired oral mucous membrane Respiratory distress or failure
7. Risk for Impaired skin integrity Pneumonia
Aspiration
8. Impaired tissue integrity of cornea
Pressure ulcer
9. Impaired urinary regulation (incontinence or retention)
Deep vein thrombosis (DVT)
10.Bowel incontinence
Contracture
11.Ineffective health maintenance 1. Positioning 30 degrees
12.Interrupted family process` 2. suctioning
 Intervention: 3. oral hygiene
4. chest physiotherapy and postural
1. Maintaining the Airway drainage,
2. Protecting the Patient: (raise the side rails) 5. mechanical ventilation, ABGs
3. Maintaining Fluid Balance and Managing Nutritional Needs: (slowly) administration of IV
fluid, nutrition therapy in the first 48 hours (ICP/CEREBRAL EDEMA)
‫في مرضى بالغيبوبة بتضل‬
4. Providing mouth care (dryness, inflammation) ‫عيونهم مفتوحه وما عندهم‬
5. Maintain skin and joint integrity (turning and message Q2h, ROM exercise) ‫ريفلكسس‬
6. Preserving Corneal Integrity (clean eyes, artificial tears every 2 hours if prescribed)
7. Maintaining body temperature (Removing all bedding, Administering acetaminophen, cool sponge baths)
8. Preventing urinary retention
9. Promoting bowel function (laxative , abdomen girth , bowel sound )
10.Restoring health maintenance
11.Meeting family’s needs
12.Monitoring and managing potential complication
 2-INCREASED INTRACRANIAL PRESSURE

 The rigid cranial vault contains brain tissue (1400 g), blood (75 mL), and CSF (75 mL) ‫االرقام مش حفظ‬
 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 ‫مهممممم‬
 ICP normal pressure being 0 to 10 mm Hg, and 15 mm Hg being the upper limit of normal
 Monro-Kellie 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:
1. displacing or shifting CSF, increasing the absorption or diminishing the production of CSF
2. decreasing cerebral blood volume.
 ICP is most commonly associated with ) head injury, brain tumors, subarachnoid hemorrhage,
and toxic and viral encephalopathies(
 Increased ICP from any cause decreases cerebral perfusion stimulate
swelling (edema) herniation ‫حطوها حلقة باذنكم‬
 Pathophysiology
1. Decreased Cerebral Blood Flow:‫ كل اشي مهم افهموها مليح‬:
 Increased ICP may reduce cerebral blood flow, resulting in ischemia and cell death
 In the early stages of cerebral ischemia, the vasomotor centers are stimulated and the
systemic pressure rises to maintain cerebral blood flow. this is accompanied by:
1-slow bounding pulse 2-respiratory irregularities
 increase in (PaCO2) causes cerebral vasodilation, leading to increased cerebral blood flow
 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.

2-Cerebral Edema
 Cerebral edema or swelling is as an abnormal accumulation of water or fluid in the
intracellular space, extracellular space, or both, cause increase in the volume of brain tissue
 Edema can occur in the gray, white, or interstitial matter
 several mechanisms attempt to compensate for the increasing ICP. 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 pressure

3-Cerebral Response to Increased Intracranial Pressure

 The brain can maintain a steady perfusion pressure if the arterial systolic blood pressure(BP) is50
to 150 mm Hg and the ICP is less than 40 mm Hg ‫احفظو االرقام مليح‬
 Changes in ICP are closely linked with cerebral perfusion pressure (CPP)
 The CPP is calculated by (MAP)-(ICP)=CPP
 Example: if the MAP is 90 mm Hg and the ICP is 10 mm Hg, then the CPP is 80 mm Hg
 normal CPP is 70 to 100 mm Hg
 If ICP is equal to MAP, cerebral circulation ceases.
 A clinical phenomenon known as the Cushing’s response (or Cushing’s reflex) is seen when
cerebral blood flow decreases significantly. When ischemic, the vasomotor center triggers an
increase in arterial pressure in an effort to overcome the increased ICP
 A sympathetically mediated response causes an increase in the systolic blood pressure with a
widening of the pulse pressure and reflex slowing of the heart rate
 It is a late sign requiring immediate intervention; however, perfusion may be recoverable if the
Cushing’s response is treated rapid
 At a certain point, the brain’s ability to autoregulate becomes ineffective and decompensation
(ischemia and infarction) begins.
 Cushing’s triad: (bradycardia, hypertension, and bradypnea) associated with this deterioration
 At this point, herniation of the brain stem and occlusion of the cerebral blood flow occur if
therapeutic intervention is not initiated
 Clinical manifestation:
 If ICP increases to the point at which the brain’s ability to adjust has reached its limits, neural
function is impaired; this may be manifested at first by clinical changes in LOC and later by
abnormal respiratory and vasomotor responses.
 change in LOC, Agitation, slowing of speech, & delay in response to verbal.
 Stuporous : reacting only to loud or painful stimuli. Early sign ‫مهممم‬
 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)
 flaccidity
 If coma is profound with pupils dilated and fixed , and respiration is impaired or absent , death
is inevitable
Assessment and Diagnostic Findings: to know cause of increased ICP
 CT scanning and MRI
 cerebral angiography, PET, or SPECT.
 Transcranial Doppler provide information about cerebral blood flow
 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 ‫سؤال سنوات‬

Complications:
1) Brain stem herniation : results from an excessive increase in ICP in which the pressure builds in
the cranial vault and the brain tissue presses down on the brain stem.
 Herniation (the shifting of brain tissue from an area of high pressure to an area of lower
pressure) and occlusion of the blood flow(ischemia, infarction and brain death) if therapeutic
intervention is not initiated.
 This increasing pressure on the brain stem results in cessation of blood flow to the brain,
leading to irreversible brain anoxia and brain death
2) Diabetes insipidus: is the result of decreased secretion of antidiuretic hormone (ADH).
 The patient has excessive urine output(polyurea) decreased urine osmolality, and serum
hyperosmolarity
 Treatment : 1)administration of fluids 2)electrolyte replacement 3)vasopressin ‫نفس ال‬ADH
3) SIADH: is the result of increased secretion of ADH. The patient becomes volume overloaded,
urine output diminishes,(oligurea) and serum sodium concentration becomes dilute ↓NA+
 Treatment of SIADH includes:
 fluid restriction (less than 800 mL/day with no free water)
 3% hypertonic saline solution
 phenytoin used to decrease ADH secretion, or Lithium to increase free water loss

Medical Management
1) Monitoring Intracranial Pressure and Cerebral Oxygenation:
 The purposes of ICP monitoring are to
1. identify increased pressure early in its course (before cerebral damage occurs),
2. to quantify the degree of elevation,
3. to initiate appropriate treatment,
4. to provide access to CSF for sampling and drainage,
5. to evaluate the effectiveness of treatment.
ICP can be monitored by :
1) ventriculostomy or ventricular catheter:
 monitoring device is used for monitoring ICP, a fine-bore catheter is inserted into a lateral
ventricle, preferably in the nondominant hemisphere of the brain
 The catheter is connected by a fluid-filled system to a transducer, which records the pressure
in the form of an electrical impulse. In addition to obtaining continuous ICP recordings, the
ventricular catheter allows CSF to drain, particularly during acute increases in pressure
 Allows administers intraventricular medication or contrast agents
 Complications: infection, meningitis, ventricular collapse, occlusion of the catheter‫مهم‬
2) subarachnoid screw or bolt:
 hollow device that is inserted through the skull into the cranial subarachnoid space
 not requiring a ventricular puncture.
 Complication: infection, blockage of the screw which lead to loss of pressure tracking
3) epidural monitor:
 Uses pneumatic flow sensor to detect ICP
 The epidural monitoring system has low risk for infection and more accurate ‫سؤال سنوات‬
 Disadvantage: inability to withdraw CSF for analysis
 Fiberoptic monitor or transducer
 The transducer reflects pressure changes which are converted to electrical signals in an
amplifier and displayed on a digital monitor
 Can be placed in to the ventricle, subarachnoid, subdural, or brain parenchyma or under
bone flap.
2) Decreasing Cerebral Edema:
 Osmotic diuretics (mannitol), urinary catheter is inserted to monitor urinary output
 corticosteroids (dexamethasone) if the increased ICP due to brain tumor.
 Fluid restriction
 Lowering body temperature to reduce metabolic rate ‫بدها دراسات اكثر وعليها خالف‬

3) Maintaining Cerebral Perfusion:

 Improvements in cardiac output are made using fluid volume and inotropic agents such as

1) dobutamine 2) norepinephrine

 effectiveness of the cardiac output is reflected in the CPP, which is maintained at greater than
70 mm Hg
4) Reducing Cerebrospinal Fluid and Intracranial Blood Volume:
 CSF drainage is frequently performed, because the removal of CSF with a ventriculostomy drain
can dramatically reduce ICP and restore CPP
  hyperventilation is used to decrease the concentration of CO2 thus vasoconstriction to decrease
blood volume ‫لما يكون الدم مشبع باالكسجين بقدر بكميه قليله من الدم يوصل كمية كبيرة من االكسجين وهيك بتقل كميه‬
‫الدم الي بتصل الدماغ وبقل الضغط‬
 PaCO2 should be maintained between 30-35 mm Hg to prevent hypoxia, ischemia, and
accumulation of cerebral lactate levels)
5) Controlling Fever:
 fever increases cerebral metabolism and the rate at which cerebral edema forms.
 Antipyretic medication, Hypothermia blanket
6) Maintaining Oxygenation and Reducing Metabolic Demands:
 Monitor ABGs and pulse oximetry
 administration of high doses of barbiturates ‫ااخر الحلول‬
 administration of paralyzing medication such as propofol (Diprivan)+ sedation meds
 Ineffective airway clearance related to diminished protective reflexes (cough, gag)
 Ineffective breathing patterns related to neurologic dysfunction (brain stem compression, structural displacement)
 Ineffective cerebral tissue perfusion related to the effects of increased ICP
 Deficient fluid volume related to fluid restriction

3-INTRACRANIAL SURGERY

 A craniotomy involves opening the skull surgically to gain access to intracranial structure
 This procedure is performed to remove a tumor, relieve elevated ICP, evacuate a blood clot or
control hemorrhage.
 Preoperative Evaluation: CT, MRI, Cerebral angiography, and transcranial Doppler flow
studies.
 Complications:
 Increased ICP,
 Infection
 neurologic deficit.
 Preoperative Management: ‫االسئله هون عشان تربطو االفكار‬
 Anticonvulsant therapy to prevent postoperative seizures
 Steroids to decrease cerebral edema ‫ستيرويد مثل شو؟‬
 Fluid may be restricted ‫ليش؟‬
 Hyperosmotic agent and diuretics may be given immediately before and sometimes during
surgery ‫هايبر اوزماتيك ايجنت مثل شو ؟‬
 Insert folly catheter ‫النه ممكن يعطوه مدر واذا ما ركبو الفوليس بعبي الدنيا‬
 Central line may administered for fluid administration and central venous pressure monitoring
after surgery
 Antibiotics and diazepam ‫ليش ؟‬
 Preparation the site of the surgery
 Postoperative Management:
 Assessing respiratory function is essential
 patient’s temperature is measured
 Reducing cerebral edema
 Relieving pain and Seizures
 Monitoring ICP
 Evaluating the level of consciousness and responsiveness to stimuli and identify any neurologic
deficit

4-Seizure Disorders

: episodes of abnormal motor, sensory, autonomic, or psychic activity that result from sudden
excessive discharge from cerebral neurons
Types of seizures: ↓ ‫عالترتيب بالصوره‬
1) - Focal Seizures originate within one hemisphere
2) Generalized seizures occurs in both hemispheres
3) -Unknown seizures such as epileptic spasms

Pathophysiology:The underlying cause is an electrical disturbance in the nerve cells in one

section of the brain
Manifestation:
1) Loss of consciousness,
2) excess movement or loss of muscle tone or movement
3) disturbances of behavior, mood, sensation, and perception

Causes of seizures:
1) Cerebrovascular disease
2) Hypoxemia of any cause, including vascular insufficiency
3) Fever (childhood)
4) Head injury
5) Hypertension
6) Central nervous system infections
7) Metabolic and toxic conditions (eg, renal failure, hyponatremia, hypocalcemia, hypoglycemia,
pesticide exposure)
8) Brain tumor
9) Drug and alcohol withdrawal
10) Allergies

Clinical Manifestation

Generalized seizure:
1) (tonic-clonic ) intense rigidity of the entire body, followed by
alternating muscle relaxation and contraction Focal seizures
#The tongue is often chewed, incontinence of urine and feces. with or without
#After 1-2 minutes the convulsive movements begin to subside, the impairment of
patient relaxes, lie deep in coma and breath noisily. consciousness or
#The respiration is abdominal awareness
#After the seziure: the patient is confused, hard to arouse, and may
sleep for hours
#Headache, sore muscles, fatigue, and depression

2) Generalized seizures (absence) my be asymptomatic ‫زي بصفن‬

‫للحضات‬

Diagnostic Findings:

1) EEG: abnormal wave patterns, focus of seizure activity

2) CT scan: a space occupying lesion
3) MRI: pathologic changes
4) BRAIN MAPPING (SPECT): identification of seizure areas

Nursing Management:

NURSING CARE DURING SEIZURE:

1) Provide privacy and protect the patient from curios on-lookers,

2) Ease the patient to the floor, if possible
3) Protect the head with a pad to prevent injury (from striking a hard surface)
4) Loosen constrictive clothing
5) Push aside any furniture that may injure the patient during the seizure
6) If the patient is on bed, remove the pillows and raise side rails
7) If an aura precedes the seizure, insert an oral airway to reduce the possibility of
the tongue or cheek being bitten

1) Do not attempt to try open jaws that are clenched in a spasm to insert anything.
Broken teeth and injury to the lips and tongue may result from such an action
2) DO NOT attempt to restrain the patient during the seizure because
muscular contractions are strong and restraint can produce injury
 3) place the patient on one side )‫(على جنبه‬with head flexed forward) ‫(راسو مثني لقدام‬,
which allows the tongue to fall forward ) ‫(عشان ما يبلع لسانه‬and facilitates drainage
of saliva and mucus. If suction is available, use it if necessary to clear secretions
 NURSING CARE AFTER THE SEIZURE: ↑‫ نقاط عليهم سؤال ركزو عليهم مليح‬3‫هضول ال‬
1) Keep the patient on one side to prevent
aspiration. Make sure the airway is patent
2) There is usually a period of confusion after
a grand mal seizure ((tonic-clonic )
3) A short apneic(‫ )توقف التنفس‬period may
occur during or immediately after a
generalized seizure
4) The patient, on awakening, should be
reoriented to the environment
5) If the patients become agitated after a
seizure (postictal), use calm persuasion
and gentle restraint
Epilepsies
 Epilepsy is a group of syndromes (‫ )مش مرض بحد ذاته‬characterized by unprovoked, recurring
seizures( seizure‫( متكرر وهاض الفرق بينه وبين ال‬
 Epileptic syndromes are classified by specific patterns of clinical features, including (age of
onset, family history and seizure type

causes: 1)primary: (idiopathic)

1) birth trauma, head injuries

2) asphyxia neonatorum (‫)نقص االكسيجين اثناء الوالده‬
Epilepsie
3) toxicity (carbon dioxide and lead poisoning) s 2)secondary: (when the
4) some infectious disease (bacterial, viral, parasitic) cause is known and the
epilepsy is a symptom of
e.g.: meningitis, encephalitis
another underlying
5) circulatory problems(strokes)
condition such as brain
6) fever, metabolic and nutritional disorder
tumor
7) drug or alcohol intoxication
8) also associated with brain tumors, abscess, and congenital malformations
9) an infection or illness that affected the developing brain of a fetus during pregnancy

Pathophysiology:
1) Messages from the body are carried by the neurons of the brain by means of discharges of
electrochemical energy that sweep along them.
2) These impulses occur in burst whenever a nerve cell has a task to perform.
3) Sometimes, these cells or groups of cells continue firing after the task is finished
4) During the period of unwanted discharges, parts of the body controlled by the errant cells
may perform erratically
5) Resultant dysfunction ranges from mild to incapacitating and often cause unconsciousness
6) When these uncontrolled, abnormal discharges occur repeatedly, a person is said to have an
epileptic syndrome
Medical Management:
Pharmacologic Therapy: ‫جدول االدويه اخر صفحه‬
1. Medications control seizures, do not cure them.
2. Medication control seizure in 70-80% of patients with seizers
3. Treatment start with single medication‫اذا ماتحكمت بالنوبات بنزيدها|اذا تحسس منها بنغيرها‬
4. Medications level in the blood are monitored ‫النه اذا زاد عن الجرعه العالجيه بتظهر سمية للدوا‬
5. If control not achieved or toxicity is high, we try another medication
Surgical Management:

Surgery is indicated for:

1) patients whose epilepsy results from (intracranial tumors, abscesses, cysts, or vascular
anomalies(
2) -seizures that do not respond to medication not ‫سؤال ترو فالس بشيلو‬

Status Epilepticus medical emergency.

Status epilepticus: (acute prolonged seizure activity) is a series of generalized seizures that
occur without full recovery of consciousness between attacks (Tocco, 2007). ‫االخ هون بحكي انه‬
‫نوبات متكرره وما بصير بينهم استعاده للوعي‬
Status epilepticus: continuous clinical or electrical seizures (on EEG) lasting at least 30
minutes, even without impairment of consciousness ‫اما التعريف الثاني بحكي انه نوبات مستمره اقل اشي‬
‫ دقيقه ومش شرط يفقد المريض وعيه‬30
 Muscular contractions impose a heavy metabolic demand and can interfere with
respiration,) ‫ (ممكن يوقف التنفس لفترات قصيره او طويله‬which lead venous congestion and hypoxia of
the brain
 Repeated episodes of cerebral anoxia and edema may lead to irreversible and fatal brain
damage
 Factors that precipitate status epilepticus include: ‫سؤال امتحان‬
1-Withdrawal of antiseizures medication 2-Fever 3-Concurrent infection
Medical Management: ABC ‫سؤال امتحان‬
1) V/S and establish adequate oxygenation and airways, intubation (endotracheal tube)
2) IV line is established and Blood samples are obtained, to monitor 1) serum electrolytes,
2) glucose, 3) phenytoin level‫ليش هضول الثالث ؟؟؟؟؟‬
3) IV infusion of dextrose if hypoglycemia is the cause
4) Diazepam, Lorazepam, or fosphyenytoin is administered slowly and immediately
5) Phenytoin, Phenobarbital are administered later to maintain seizure free state
6) EEG monitoring may be useful in determining the nature of seizure activity
7) neurologic signs are monitored continuously
8) UNRESPONSE? General anesthesia with a short-acting barbiturate may be used.
 ‫بالبداية بعطي المريض ديزيبام و لورازيبان (من نفس العائلة الدوائيه بنزوديزيبين) ومعهم فوسفينيتوين خالل النوبة ركزو‬

Nursing management
 Initiates ongoing assessment and monitoring of respiratory and cardiac functioning
Monitoring and documenting the seizure activity and the patient’s responsiveness ‫النه االعراض‬
‫خالل النوبه بتعطيك فكره عن موقع حدوثها بالدماغ‬
 The patient is turned to a side lying position to assist in draining pharyngeal secretions
 The IV line must be closely monitored because it may be dislodged during seizure ‫المريض بتحرك‬
‫وبشيل الكانيوال‬

5-Headache

 the most common of all human physical complaints ,not a disease entity but a symptom
 it may indicate – organic disease, stress response, vasodilation, skeletal muscle tension
Types:
 Primary headache: no organic cause. E.g : Migraine, tension-type, cluster headache
 Secondary headache: symptom associated with another organic cause such as tumor or
aneurysm
 Headache can be triggered by (menstrual cycle, bright light, stress, depression, sleep
deprivation, fatigue, over use of certain medication such as oral contraceptive, and some milk
product.)
1) Migraine:
 is Periodic and recurrent attacks of severe headache lasting from 4-72 hours ‫عليهم‬
 Hereditary and associated with low magnesium levels ‫سؤال‬
 It results from vascular disturbance
 The typical onset is at puberty
 Incidence is higher among women
 Migraine without aura is more common than with aura
 Pathophysiology: varying degrees of cortical ischemia followed by vasodilation.
 Abnormal metabolism of Serotonin (Vasoactive neurotransmitter). Rise in plasma serotonin,
dilate the extracranial carotid artery and constrict the intracranial carotid artery. This process
is followed by a fall in plasma serotonin (vasodilation) and a pulsating, throbbing
pain. Vasoactive neurotransmitter ‫نواقل عصبية بتوسع او بتضيق االوعية الدمويه‬

‫النقاط الي فوق مههههممممات‬

Migraine phases:

 PRODROME:- experienced by 60% of patient

 symptoms: depression, Irritability, feeling cold, increase urination, food craving, anorexia,
change in activity level, diarrhea or constipation
 AURA PHASE: occurs in up to 31% of patient , less than an hour, characterized by: focal
neurologic symptoms such as visual disturbances and may be hemianopic(‫)بعين وحده‬, corresponds
to the painless vasoconstriction, other symptoms (numbness and tingling of the lips, face or
hands, mild confusion, slight weakness of an extremity, drowsiness, dizziness)
 Headache Phase: A throbbing headache intensifies over several hours, Severe and
incapacitating, Associated with photophobia, phonophobia nausea and vomiting, Duration
varies from 4 – 72 hours
 Recovery Phase: The pain gradually subsides, Muscle contraction in the neck and scalp is
common, Associated with muscle ache and localized tenderness, exhaustion and mood
changes, Physical exertion exacerbates headache pain, Postheadache phase patient may sleep
for extended periods
Migraine Treatment:
 Abortive (symptomatic) approach – best employed in patients who suffer less
frequent attacks; is aimed at relieving or limiting a headache at the onset or while it is in
progress ‫يعني ما بوخذ دوا بانتظام‬ ‫للمرضى الي نادر ما تصيبه وبنعالج االعراض وقت حدوثها‬
 Preventive approach – used in patients who experience more frequent attacks at regular
or predictable intervals and may have medical conditions that preclude the use of abortive
therapies
 Triptans:, serotonin receptor agonist – are the most specific antimigraine agents; cause
vasoconstriction, reduce inflammation, and may reduce pain transmission
 Ergotamine tartrate – acts on smooth muscle, causing prolonged constriction of the
cranial blood vessels ‫ممنوع نوخذ التربتان مع االرجوتامين مع بعض‬
 Side effects include: aching muscle, paresthesia , nausea and vomiting
2) Tension headache
 Tension-type headache is the most common type of
headache, chronic, and less sever type
 Related to tension
 Episodic, vary with stress
 Usually bilateral, involves neck and shoulders
 Characterized by a steady
 Often bandlike or “a weight on top of my head”
 Symptoms : sustained contraction of head and
neck muscles
Tension Headache treatment:
3) Non-narcotic analgesics ‫مثل االسبرين والبروفن والريفانين‬
4) relaxation technique
5) Amitriptyline )‫معلومه زياده هاض ترايسايكليك بستخدموه لعالج االحباط وبرفع تركيز السيراتونين (هرمون السعاده‬

3)Cluster headaches:
 sever form of vascular headaches, more among men than women
 More common in older men
 Precipitated by alcohol or nitrate ‫ليش‬
 Episodes cluster together in quick succession for few days or weeks with remission that lasts for
months ‫بتيجي بشكل متتابع أليام او اسابيع وبتعافى منها خالل شهور‬
 Intense, throbbing, deep, often unilateral pain, begin in infraorbital region and spread to head
and neck
 Each attacks last (30 – 90) minutes and may have crescendo- decrescendo pattern
 Symptoms:
3) Flushing, Tearing of eyes,
4) Nasal stuffiness,
5) Sweating,
6) Swelling of temporal vessels

Cluster Headache treatment:

1) Narcotic analgesic I.M. ‫مثل المورفين‬
‫واالوكسيكودون‬
2) during acute phase, 100% oxygen by
face mask for 15 minutes,
3) ergotamine tartrate
4) sumatripan
5) steroids Percutaneous
6) sphenopalatine ganglion blockade ‫مخدر موضعي‬
4) Cranial arteritis
Cause of headache in older population, reaching its
greatest incidence in those older than 70 years old

Symptoms:
Fatigue, Malaise, Weight loss, Fever, Tender, swollen or
nodular temporal artery is visible

Cranial arteritis treatment :

Early administration of corticosteroid to prevent the
possibility of loss of vision due to vascular occlusion or rupture of the involved artery

5)Secondary Headache
 Associated with organic cause such as brain tumor or aneurysm
 Serious disorder related to headache include: brain tumors, subarachnoid hemorrhage,
stroke, sever hypertension, meningitis, head injuries
Assessment and Diagnostic Findings:
 Detailed history and physical assessment
 Data obtained for the health history should reflect
patient’s own words
 Focus health history on assessment of headache
(location, quality, frequency, precipitating factors,
time, associated symptoms)
diagnostic procedure
1) CT Scan
2) Cerebral angiography
3) MRI
4) EMG – reveal a contraction of the neck, scalp, or
facial muscles
Laboratory Test :

CBC, electrolytes, creatinine

sedimentation rate,
glucose thyroid hormone level
  Prevention
 Avoid specific triggers that are known to initiate the headache syndrome.
Medication therapy:
1. Propranolol ( inderal) the mostly wide used medication, ‫ندير بالنا اذ المريض عنده ازمه او سكري‬
‫او تباطئ بضربات القلب‬
2. calcium antagonists ( Verapamil HCL) ‫ندير بالنا من ال نزول الضغط‬
3. Methysegide (Sansert) block the effect of seratonin,
4. Anticonvulsants, antidepressent, barbiturates, tranquilizer.
5. Avoid vasodilators, alcohol, nitrites, and histamines

Nursing Management:
 Relieving Pain
1) Attempt to abort headache early abort → ‫مش اجهاض معناها هون اوقف الصداع‬
2) Provide comfort measures(quite dark environment), elevate head 30 degrees
3) Provide symptomatic treatment such as antiemetics as indicated
 Promoting Home and Community based care:
1. Teach that migraine headaches are likely to occur when patient is ill, overtired, or feeling
stressed
2. Instruct about the importance of proper diet, adequate rest, and coping strategies
3. Help patient identify circumstances that precipitate headache, and assist in development of
alternative means of coping
4. Help patients develop insight into their feelings, behaviors, and conflicts to make necessary
lifestyle modifications
5. Suggest regular periods of exercise and relaxation and avoidance of offending factors
6. Avoid long intervals between meals ‫ليه‬
7. Advise patient to awaken at the same time each day; disruption of normal sleeping pattern
provokes a migraine in may patient
8. Avoid food like :