Transcript NURS 768 Powerpoint presentation

CAPSTONE PRESENTATION
NURS 768: PRIMARY CARE III
Chu, Wai Ling Kennis, GNP/ANP Student
Spring 2011
CC: Seizure and LOC
H&P: 71 yrs old white male had body shaking x 3 mins,
was unresponsive, and had blood coming out of his
month while he was sleeping. Pt LOC for 30 mins, woke
up in ambulance with unclear voice asking “where am I
going”. He denies nightmare, no hx of seizure or head
trauma, had flu-like S&S x 2 weeks but no fever,
symptoms relieved by OTC medicine, no change in old
meds. Upon admission, Ativan 2 mg given. In ER, pt has
left arm jerking x 2 with his HR slow down to 30 &
asystole x 1 sec, BP 110/45 while he was asleep. He
responds immediately to tactile stimulus, denies
abnormal feeling before and after the jerking.
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PMH: HTN, Hypercholesterolemia, CAD
PSH: GABG
Allergy: NKA
Social Hx: Retired letter carrier, never smoke, drink a
glass of wine after dinner occasionally, denies illegal
drug use; no regular exercise, regular diet with night
time snack.
Family Hx: Father, CHF; Mother, Stomach CA.
Immunizations: Pneumoncoccal in 2005, Influenza in
12/2010.
Screening test: Stress test in 02/2011, negative.
Medications: Atenolol 50 mg PO qd, ASA 81 mg PO qd,
Zocor 40 mg PO qhs, Allegra 60 mg po and Afrin nasal
sprays as needed.
Review of Systems
 HEENT: Denies eye, ear, or nose problems, no
headache or dizziness, mild sore tongue 20 to tongue
bite during sleep, no sore throat or difficulty swallowing.
 Resp: Denies trouble breathing, denies sleep apnea.
 CV: No chest pain, pressure, no palpitation.
 GI: Denies urinary or GI problem, no incontinence.
 Musculoskeletal: Body shaking x 1, witnessed by wife.
 Neuro: Denies weakness, numbness, incoordination,
no fainting or memory loss; denies depression,
insomnia, or sleeping problems.
Physical Exam
 V/S : BP 123/88, HR 90, R24, T98.2 F, O2 Sat 95%
with O2 3L n/c, fasting BS 128 mg/dl upon admission.
 General Appearance: Tired looking, oriented x 3 except
unable to recall what happened before he was in the
ambulance. Ht 179 cm , Wt 216 lbs, BMI 31.9. Skin
warm, no rashes or lesion.
 HEENT: Normocephalic/atraumatic; PERRLA, EOMI,
no nystagmus; normal hearing; no nasal discharges or
sinus tenderness; mild ecchymotic abrasion noted in
the left side of tongue, no swelling or active bleeding,
gag reflex intact; throat pink, no exudates, mild slurred
speech 20 to tongue trauma, speech is articulate.
Physical Exam Cont’d
 Resp: Normal breath sounds, no coughing, wheezing,
rales, or stridor. Loud snoring observed when sleeping.
 CV: Normal S1 & S2, no heart murmur, no JVD, no
carotid bruit; no edema.
 GI/GU: Abd soft, non-distended, non-tendered, no
penile discharge, ulcers, mass or hernia.
 Neuro: Cranial nerves I to XII grossly intact, no focal
deficit, no tremor or seizure activities at most time
except 2 episodes of left hand jerking during sleep;
sensory intact, appropriate coordination, normal
reflexes; no cognitive impairment. Mini-mental state
exam score is 26 and NIH Modified Stroke Scale is 1.
Diagnostic Tests
15.1
7.2 44.2 137
143
5.5
103 14
19
1.0
208
Cal 9.9, Mg 2.5, Troponin I <0.012, CK-MB 1.3, Total CK
104
UA: Negative
EKG: Regular sinus rhythm with prolonged QT interval
0.48 second.
Chest X-ray: Unremarkable
Head CT w/o contrast: Unremarkable. No evidence of
cerebral infarct or hemorrhage.
Blood culture and urine culture: Results are pending.
Differential diagnosis & Pathophysiology
Epileptic seizure: A transient occurrence of S&S such as
limb-shaking due to abnormally excessive neuronal
activity of the brain. It is associated with a prior CNS
insult such as infection, stroke, brain trauma, etc. or
an unknown etiology (AlEissa & Benbadis, 2011). In
temporal or frontal lobe seizures, ictal bradycardia
and asystole might occur (Maromi, 2009). After a
grand mal seizure, CK levels are often elevated and
remain for several hours or a day (Nguyen & Kaplan,
2010).
Rule In: Tongue biting, LOC, bradycardia and asystole.
Rule Out: Normal WBC & CK level, no fever, no aura, no
incontinence, unremarkable head CT, no history of
head trauma, seizure, or stroke, symptoms less than
24 hours.
Causes of Seizure in Different Age group
Source: http://www.epilepsyadvocate.com.
Transient Ischemic Attacks: TIAs may be mistaken for
seizures, but may also induce seizures. It’s caused by
temporary loss of blood flow to the brain due to a blood
clot. The ischemia reduced neural activity causing
sensory loss, muscle weakness, or trouble speaking. It
doesn’t cause brain tissue to die and it doesn’t show
changes on CT or MRI scans because the blockage
breaks up quickly and dissolves. The causes of TIA
include A. fib and inflammation of brain arteries, etc, risk
factors include HTN, smoking, DM (Zieve & Hoch, 2010).
Rule In: Unclear speech, hx of HTN, CAD and old age.
Rule Out: No muscle weakness, sensory intact, no
indication of hypercoagulation, no hx of a. fib. Low Stroke
Scale Score.
Brain Neoplasm: About 1/3 of people with a brain tumor
are not aware until they have a seizure. Seizures are
caused by a disruption in the normal flow of electricity
in the brain by the tumor. It might also cause headache,
mental or personality change, hearing problem, double
vision, decrease sensation, or muscle weakness
(ABTA, 2010). Brain tumors are more common in white
males and usually detected in the old age. Risk factors
include radiation, chemical exposure, family hx of
gliomas (National Cancer institute, 2008).
Rule In: Seizure, old age, white male.
Rule Out: No focal deficit, no headache or personality
change, negative head CT scan, no hx of excessive
radiation or chemical exposure.
Meningitis/Encephalitis: They are infections in the brain
and spinal cord caused by bacterial, viral, fungal
infection; inflammatory diseases such as lupus; cancer
or head and spine injury. Meningitis/Encephalitis cause
dangerous inflammation which can produce a wide
range of symptoms including flu-like symptoms,
nausea, vomiting, confusion, photophobia and seizures
(NINDS, 2011). The classic meningitis triad of fever,
headache, and nuchal rigidity develops over hours or
days (Merck & Co, 2011).
Rule In: Recent flu-like symptoms, seizure activity
Rule Out: No fever, headache, or neck rigidity, no
complaint of confusion or photophobia, WBC negative,
improved flu-like symptoms.
Convulsive Syncope: Syncope is commonly
misdiagnosed as epilepsy because it was believed that
is a limp motionless events, in fact, it frequently
involves brief body jerks (Benbadis, 2009). It is an
abrupt LOC because of the reduction of cerebral
perfusion and cerebral hypoxia. In syncope, CK level
rarely elevated, unless patient had a MI (Nguyen &
Kaplan, 2010). A variety of cardiovascular disorders
such as arrhythmia can cause the sudden fall in
cerebral perfusion by decrease cardiac output. Other
causes including drug effects, electrolyte imbalance,
and dehydration (AlEissa & Benbadis, 2011).
Rule In
Why it is Convulsive Syncope?
 A brief motor activity including tonic extension of the
trunk and limbs or several clonic jerks can occur in
uncomplicated syncope (Nguyen & Kaplan, 2010).
 Unlike epilepsy, patients usually wake up quickly after a
syncopal event (Nguyen & Kaplan, 2010). Despite the
suspected episode of generalized tonic-clonic seizure
prior to admission, this patient is easy arouse by tactile
stimulus from the 2 seizure-like activities.
 Pt’s CK level within normal range
 Pt’s hx of HTN, CAD, current sick sinus syndrome,
prolonged QT interval, hyperkalemia, all of these put
him on high risk of sudden fall in cerebral perfusion and
syncope by decreased cardiac output.
“Many patients who have a single seizure do not require
anticonvulsant therapy…This decision is based on a
discussion of the risk of seizure recurrence, the
effectiveness of anticonvulsant treatment, and the
adverse medical and socioeconomic effects of
anticonvulsant treatment” (AlEissa and Benbadis, 2011).
Treatment Plan
 Airway maintenance and seizure precaution
 Ativan 2 mg IV q6hrs prn
 100% non-rebreather
 Maintain cardiac output
 External pacemaker
 Transvenous pacemaker insertion
 Close serum potassium and blood sugar monitoring
 EEG monitoring & Neurologist consult
 Weight loss and diet control
 Regular exercise
 Patient and family education
References
AlEissa, E, I, MBBS, MD & Bebadis S, R, MD (Jan, 2011). First seizure in adulthood.
Retrieved March 06, 2011 from http://emedicine.medscape.com/article/1186214print
American Brain Tumor Association. (2010). Seizures. Retrieved March 14, 2011 from
http://www.abta.org/
Benbadis, S. (2009). The differential diagnosis of epilepsy: A critical review. Retrieved
March 18, 2011 from http://www.epilepsyfoundation.org
Boggs, J. G. (2010). Seizures and epilepsy in the elderly: Etiology, clinical presentation,
and differential diagnosis. Retrieved March 12, 2011 from
http://www.uptodate.com.
Centers for Disease Control and Prevention. (2011). Healthy Weight – it’s not a diet,
it’s a lifestyle. Retrieved April 05, 2011 from http://www.cdc.gov/healthyweight/
Deglin, J.H. & Vallerand, A. H. (2010). Nursing Central from Unbound Medicine
handheld platform. Davis’s Drug Guide, 2010. [PDA Software]. Philadelphia, PA:
F. A. Davis Company.
Epocrates. (2011). Epocrates Essentials: Version 3.16. Horizon BCBSNJ Classic-PDL.
[PDA Software]. BMJ Publishing Group Ltd.
Folstein, M.F., Folstein, S., & McHugh, P.R. (1975). “Mini-mental state": A practical
method for grading cognitive state of patients for the clinician. Retrieved February
22, 2010 from http://utswfm.googlepages.com/NH_MMSE.pdf.
Harrigan, R.A., & Chan, T.C., & Moonblatt, S., & Vilke, G.M., & Ufberg, J.W. (2007).
Temporary transvernous pacemaker placement in the Emergency Department.
Retrieved April 03, 2011 from http://www.ncbi.nlm.nih.gov/pubmed/
References
Kanjwal, K., Karabin, B., Kanjwal, Y., & Grubb, B.P. (2009). Differentiation of convulsive
syncope from epilepsy with an implantable loop recorder. Retrieved April 02, 2011 from
http://www.medsci.org/v06p0296.pdf
Maromi, N, MD. (2009). “Cardiac effects of seizures”. Retrieved March 11, 2011 from
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2728482/
Mathur, R.M.D., & Shiel, W. C. M.D, FACP, FACR. (2009). Hemoglobin A1c Test. Retrieved
April 03, 2011 from http://www.medicinenet.com/hemoglobin_a1c_test/article.htm
Merck & Co., Inc. (2011). Nursing Central from Unbound Medicine handheld platform. The
Merck Manual, Professional edition,2011. [PDA Software]. Philadelphia, PA:F.A. Davis
Company.
Minczak, B.M., MD, PhD. (2007). Seizures – What is the mechanism underlying clinical
manifestations of seizure activity as seen in the ED? Retrieved April 08, 2011 from
http://acep.org.content.aspx?id=33508
National Cancer Institute. (2008). Brain tumor. Retrieved April 3, 2011 from
http://www.medicinenet.com
National Institute of Neurological Disorders and Stroke. (2011). Meningitis and Encephalitis
Fact Sheet. Retrieved March 18, 2011 from http://www.ninds.nih.gov
National Kidney Foundation. (2011). Glomerular Filtration Rate (GFR). Retrieved April 03,
2011 from http://www.kidney.org/kidneydisease/ckd/knowgfr.cfm
Nei, M., MD. (2009). Current review in clinical science: Cardiac effects of seizures. Retrieved
March 11, 2011 from http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2728482/
Nguyen, T. T., & Kaplan, P. W. (2010). Nonepileptic paroxysmal disorders in adolescents and
adults. Retrieved March 21, 2011 from www.uptodate.com.
Sovari, A.A., & Kocheril, A. G. (2010). Long QT Syndrome. Retrieved March 11, 2011 from
http://emedicine.medscape.com/article/157826-print
References
Stoppler, M.C., MD., & Shiel, W. C., MD, FACP, FACR. (2008). Hyperkalemia (High blood
potassium). Retrieved April 03, 2011 from http://www.medicinenet.com
U.S. National Library of Medicine (NLM), (2011). Hypercholesterolemia. Retrieved April 05,
2011 from http://ghr.nlm.nih.gov/condition/hypercholesterolemia
Venes, D. M.D. (2009). Nursing Central from Unbound Medicine handheld platform.
Taber’s cyclopedic medical dictionary, 21st Edition. [PDA Software]. Philadelphia, PA:
F.A. Davis Company.
Zieve, D, MD, MHA., & Hoch, D. B., PhD, MD. (2010). Transient ischemic attack. Retrieved
March 19, 2011 from http://www.nlm.nih.gov/medlineplus/ency/article/000730.htm.