ALTERED LEVEL OF ALTERED LEVEL OF CONSCIOUSNESSCONSCIOUSNESS

Definition:Definition:

Is Apparent in patient who is not Is Apparent in patient who is not oriented, does not follow commands, oriented, does not follow commands, or needs persistent stimuli to achieve or needs persistent stimuli to achieve state of alertness.state of alertness.

Level of consciousness is gauged as Level of consciousness is gauged as a continuum with a normal state of a continuum with a normal state of alertness and full alertness and full cognition( consciousness) on one end cognition( consciousness) on one end or coma on the other end.or coma on the other end.

COMA > is a clinical state of COMA > is a clinical state of unconsciousness in which the patient unconsciousness in which the patient is unaware of self or the environment is unaware of self or the environment for prolonged periods.for prolonged periods.

AKINETIC MUTISM > a state of AKINETIC MUTISM > a state of unresponsiveness to the environment unresponsiveness to the environment which the patient makes no movement which the patient makes no movement or sounds but sometimes opens the or sounds but sometimes opens the eyes.eyes.

PERSISTENT VEGETATIVE STATE > is a PERSISTENT VEGETATIVE STATE > is a condition which the patient is condition which the patient is described as wakeful but devoid of described as wakeful but devoid of conscious content, without cognitive conscious content, without cognitive or affective mental function.or affective mental function.

PATHOPHYSIOLOGYPATHOPHYSIOLOGY:: Altered LOC is not a disorder itself: but it is a Altered LOC is not a disorder itself: but it is a

function and a symptom of multiple of physiologic function and a symptom of multiple of physiologic phenomena.phenomena.

The underlying cause of neurologic dysfunction in The underlying cause of neurologic dysfunction in cells of nervous system, neurotransmitters, or cells of nervous system, neurotransmitters, or brain anatomy.brain anatomy.

A disruption in the basic functional units or A disruption in the basic functional units or neurotransmitters results in a faulty impulse neurotransmitters results in a faulty impulse transmission impending communication within the transmission impending communication within the brain or from the brain to the other parts of the brain or from the brain to the other parts of the body.body.

The brain stems contains areas that control the The brain stems contains areas that control the heart, respiration and blood pressure.heart, respiration and blood pressure.

Disruptions of the anatomic structures are Disruptions of the anatomic structures are caused by trauma, edema, pressure from tumors caused by trauma, edema, pressure from tumors as well as other mechanisms such as increased or as well as other mechanisms such as increased or decreased in blood in CSF circulation.decreased in blood in CSF circulation.

LEVEL OF LEVEL OF CONSCIOUSNESSCONSCIOUSNESS:: LEVEL I- CONSCIOUSLEVEL I- CONSCIOUS > normal awareness > normal awareness

oriented to time, person, and place.oriented to time, person, and place.LEVEL II- LETHARGY SOMNOLENCE LEVEL II- LETHARGY SOMNOLENCE DROWSINESS OR OBSTUNDATION >DROWSINESS OR OBSTUNDATION > responds responds with confusion alone, falls alone to sleep; with confusion alone, falls alone to sleep; responds briefly to stimuli.responds briefly to stimuli.LEVEL III- STUPORLEVEL III- STUPOR > physical and mental > physical and mental activity is minimal.activity is minimal.> Reflexes and sphincter actions are not > Reflexes and sphincter actions are not changed.changed.> Patient awareness by vigorous stimulation.> Patient awareness by vigorous stimulation.LEVEL IV- SEMI-COMALEVEL IV- SEMI-COMA > no spontaneous > no spontaneous movement, withdrawal from painful stimuli movement, withdrawal from painful stimuli and verbal response are limited to groaning.and verbal response are limited to groaning.> vomiting.> vomiting.> reflex activities.> reflex activities.COMA OR DEEP COMACOMA OR DEEP COMA > no spontaneous > no spontaneous movement.movement.  

ASSESSMENT AND ASSESSMENT AND DIAGNOSTIC FINDINGS:DIAGNOSTIC FINDINGS:

Glasgow Coma ScaleGlasgow Coma Scale evaluation of mental statusevaluation of mental status cranial nerve functionalcranial nerve functional reflexesreflexes motor and sensory functionalmotor and sensory functional

LABORATORY TESTS LABORATORY TESTS INCLUDEINCLUDE:: analysis of blood glucoseanalysis of blood glucose electrolyteselectrolytes serum ammoniaserum ammonia blood urea nitrogen levelblood urea nitrogen level serum osmolalityserum osmolality calcium levelcalcium level partial thromboplastin and partial thromboplastin and

prothrombin timesprothrombin times serum ketone and alcohol serum ketone and alcohol drug levelsdrug levels arterial blood gas levelarterial blood gas level

COMPLICATIONS:COMPLICATIONS: respiratory failurerespiratory failure pneumoniapneumonia pressure ulcerspressure ulcers aspirations from GI tractaspirations from GI tract

MEDICAL MANAGEMENT:MEDICAL MANAGEMENT: maintain patent airwaymaintain patent airway patient may be orally and nasally intubatedpatient may be orally and nasally intubated tracheotomytracheotomy mechanical ventilator- maintain adequate mechanical ventilator- maintain adequate

oxygenationoxygenation intravenous catheterintravenous catheter nutritional support > feeding tube; nutritional support > feeding tube;

gastrostomy gastrostomy

NURSING INTERVENTIONSNURSING INTERVENTIONS:: maintaining the airwaymaintaining the airway protecting the patientprotecting the patient maintaining the fluid and balance monitoringmaintaining the fluid and balance monitoring providing mouth careproviding mouth care maintaining skin and joint integritymaintaining skin and joint integrity preserving corneal integritypreserving corneal integrity achieving thermoregulationachieving thermoregulation promoting bowel functionalpromoting bowel functional providing sensory stimulationproviding sensory stimulation meeting family needsmeeting family needs monitoring and managing potential complicationsmonitoring and managing potential complications

GLASGOW COMA GLASGOW COMA SCALESCALE

DEFINITION:DEFINITION:• evaluates level of consciousness

• objective measurement of level of consciousness sometimes called quick neuro check

MOTOR RESPONSE POINTS:MOTOR RESPONSE POINTS:

6 = obeys simple response5 = localized painful stimuli4 = normal flexion ( withdrawal)3 = abnormal flexion ( decortication)2 = extensor response

( decerebration)1 = no response

VERBAL RESPONSE:VERBAL RESPONSE:

5 = oriented4 = confused conversation3 = inappropriate word2 = response with

comprehensible sounds1 = no verbal response

EYE OPENING POINTS:EYE OPENING POINTS:

4 = spontaneous3 = in response to sound2 = response to pain1 = no response event to

painful stimuli 

INTERPRETATIONS:INTERPRETATIONS:

15 – 14 = conscious13 – 11 = lethargy10 – 8 = stupor7= semi- coma3= deep coma

TEST OF MEMORY:TEST OF MEMORY:

SHORT TERM MEMORY • positive result mean anterograde

amnesia and damage to temporal lobe.

• Ask most recent activity.

LONG TERM ACTIVITY• positive result mean retrograde

amnesia and damage to limbic system.

• Consider educational background.

INCREASED INTRACRANIAL INCREASED INTRACRANIAL PRESSURE (ICP)PRESSURE (ICP)

an increased ICP caused by an increased ICP caused by trauma, hemorrhage, growth of trauma, hemorrhage, growth of tumors, hydrocephalus, edema tumors, hydrocephalus, edema or inflammation.or inflammation.

Can impede circulation to the Can impede circulation to the brain, impede the absorption of brain, impede the absorption of CSF, affect the functioning of CSF, affect the functioning of nerve cells, and lead to brain nerve cells, and lead to brain stem compression and death.stem compression and death.

PATHOPHYSIOLOGY:PATHOPHYSIOLOGY: increased in ICP is a syndrome increased in ICP is a syndrome

that affect many patients with that affect many patients with acute neurologic conditions.acute neurologic conditions.

An elevated ICP most commonly An elevated ICP most commonly associated with head injury, it associated with head injury, it also may be seen as a also may be seen as a secondary effect in other secondary effect in other conditions, such as brain conditions, such as brain tumors, subarachnoid tumors, subarachnoid hemorrhage, toxic and viral hemorrhage, toxic and viral encelophaties.encelophaties.

Increase ICP from any cause Increase ICP from any cause decreased cerebral perfusion, decreased cerebral perfusion, stimulates further swelling and stimulates further swelling and shifts brain tissue through shifts brain tissue through openings in they rigid dura, openings in they rigid dura, resulting in herniation.resulting in herniation.

CLINICAL CLINICAL MANIFESTATIONSMANIFESTATIONS:: any sudden change in patient's any sudden change in patient's

condition, such as restlessness condition, such as restlessness without apparent cause, confusion without apparent cause, confusion or increasing drowsiness, has or increasing drowsiness, has neurogic significance.neurogic significance.

Comprehension of the brain due to Comprehension of the brain due to swelling from hemorrhage or swelling from hemorrhage or edema.edema.

Expanding intra cranial lesion.Expanding intra cranial lesion. As ICP increase, patient becomes As ICP increase, patient becomes

stuporous.stuporous. As neurologic function deteriorates, As neurologic function deteriorates,

patient becomes comatose and patient becomes comatose and exhibits abnormal motor response exhibits abnormal motor response in the form of decortication, in the form of decortication, decerebration or flaccidity.decerebration or flaccidity.

ASSESSMENT:ASSESSMENT: assess LOC, which is the most sensitive assess LOC, which is the most sensitive

and earliest indication of increasing ICP.and earliest indication of increasing ICP. Declining LOC from restlessness to Declining LOC from restlessness to

confusion and coma.confusion and coma. HeadacheHeadache abnormal respirationsabnormal respirations increase in BP with widening pulseincrease in BP with widening pulse slowing of pulseslowing of pulse elevated temperatureelevated temperature pupil changespupil changes change in motor functions from weakness change in motor functions from weakness

to hemiplegia, a positive Babinski reflex, to hemiplegia, a positive Babinski reflex, decorticate, decerebrate posturing and decorticate, decerebrate posturing and seizures.seizures.

Late signs of increase ICP include Late signs of increase ICP include increased systolic BP widened pulse increased systolic BP widened pulse pressure and slowed heart ratepressure and slowed heart rate

COMPLICATIONS:COMPLICATIONS:

brain stem herniation- results brain stem herniation- results in increase ICPin increase ICP

Diabetes InsipidusDiabetes Insipidus Syndrome of Innapropriate Syndrome of Innapropriate

Antidiuretic Hormone Antidiuretic Hormone (SIADH)- results in over (SIADH)- results in over secretion of antidiuretic secretion of antidiuretic hormone.hormone.

  excessive urine output and excessive urine output and hyperosmolality results.hyperosmolality results.

MEDICATIONS AND MEDICATIONS AND MANAGEMENT:MANAGEMENT: MONITORING ICPMONITORING ICP > to quantify the degree of > to quantify the degree of

evaluation, to initiate appropriate treatment- evaluation, to initiate appropriate treatment- VENTRICULOSTOMY, SUBARACHNOID BOLT, VENTRICULOSTOMY, SUBARACHNOID BOLT, EPIDURAL or SUBDURAL CATHETER.EPIDURAL or SUBDURAL CATHETER.

MANNITOL (OSMITROLMANNITOL (OSMITROL) > Hyperosmotic ) > Hyperosmotic agent; increased intravascular pressure by agent; increased intravascular pressure by drawing fluid from the interstitial spaces and drawing fluid from the interstitial spaces and from the brain cells.from the brain cells.

CORTICOSTEROIDSCORTICOSTEROIDS > stabilizes the cell > stabilizes the cell membrane and reduce the leakiness in the membrane and reduce the leakiness in the blood-brain barrier.blood-brain barrier.

> A histamine blocker may > A histamine blocker may be administered to counteract the excess be administered to counteract the excess gastric secretion that occurs with gastric secretion that occurs with corticosteroid.corticosteroid.

> client must be withdrawn > client must be withdrawn slowly from corticosteroid therapy to reduce slowly from corticosteroid therapy to reduce the risk of adrenal crisis.the risk of adrenal crisis.

BLOOD PRESSURE MEDICATIONBLOOD PRESSURE MEDICATION > required to > required to maintain cerebral perfusion at a normal level.maintain cerebral perfusion at a normal level.> notify the physician if the BP range is below > notify the physician if the BP range is below 100 or above 150mm Hg systolic. 100 or above 150mm Hg systolic.

ANTIPYERETIC AND MUSCLE RELAXANTSANTIPYERETIC AND MUSCLE RELAXANTS > > temperature reduction decreases metabolism, temperature reduction decreases metabolism, cerebral blood flow, and thus ICP.cerebral blood flow, and thus ICP.> prevents shivering.> prevents shivering.

ANTICONVULSANTSANTICONVULSANTS > may be given > may be given prophylactic ally to prevent seizures.prophylactic ally to prevent seizures.> seizures increase metabolic requirements and > seizures increase metabolic requirements and cerebral blood flow and volume and increase cerebral blood flow and volume and increase ICP.ICP.

IV FLUIDSIV FLUIDS > administration via infusion pump to > administration via infusion pump to control the amount of IV fluid treatment.control the amount of IV fluid treatment.> Hypertonic IV solutions are avoided because > Hypertonic IV solutions are avoided because of the risk of promoting additional cerebral of the risk of promoting additional cerebral edema.edema.  

INTERVERNTIONS:INTERVERNTIONS: elevate the head of the bed 30 to 40 elevate the head of the bed 30 to 40

degrees as prescribed .degrees as prescribed . Avoid trendeleburg positionAvoid trendeleburg position prevent flexion of neck and lips.prevent flexion of neck and lips. Monitor respiratory status and Monitor respiratory status and

prevent hypoxiaprevent hypoxia maintain mechanical ventilations as maintain mechanical ventilations as

prescribed, maintaining PaCO2 at 30 prescribed, maintaining PaCO2 at 30 to 35 mm Hg, which will result in to 35 mm Hg, which will result in vasoconstriction of cerebral blood vasoconstriction of cerebral blood vessels, decreased blood flow and vessels, decreased blood flow and therefore decrease ICP.therefore decrease ICP.

Maintain body temperature.Maintain body temperature.

SEIZURESEIZURESS

TYPES OF SEIZURE:TYPES OF SEIZURE:GENRALIZED SEIZURE:GENRALIZED SEIZURE:TONIC CLONIC ( GRAND MAL )TONIC CLONIC ( GRAND MAL )> may begin with an aura.> may begin with an aura.> this phase may be involves the stiffening or rigidity of the > this phase may be involves the stiffening or rigidity of the

muscles of the arms and legs usually lasts 10 to 20 seconds muscles of the arms and legs usually lasts 10 to 20 seconds followed by loss of consciousness.followed by loss of consciousness.

> this phase consists of hyperventilation and jerking of the > this phase consists of hyperventilation and jerking of the extremities and usually lasts about 30 seconds.extremities and usually lasts about 30 seconds.

> full recovery from seizures may take several hours.> full recovery from seizures may take several hours.ABSENCEABSENCE> brief seizures lasts seconds and the individual may or may > brief seizures lasts seconds and the individual may or may

not lose of consciousness.not lose of consciousness.> no loss or change in muscle tone occurs.> no loss or change in muscle tone occurs.> seizure may occur several times a day.> seizure may occur several times a day.>Victim appears to daydreaming.>Victim appears to daydreaming.> this type of seizure is more common in children.> this type of seizure is more common in children.

MYOCLONIC MYOCLONIC >a seizure that presence as a brief generalized >a seizure that presence as a brief generalized jerking or stiffening of extremities.jerking or stiffening of extremities.> the victim may fall to ground as a result of seizure.> the victim may fall to ground as a result of seizure.ATONIC OR AKINETIC ( DROP ATAACKS )ATONIC OR AKINETIC ( DROP ATAACKS )> a sudden momentary loss of muscle tone.> a sudden momentary loss of muscle tone.> The victim may fall to ground as a result of the seizure.> The victim may fall to ground as a result of the seizure.PARTIAL SEIZUREPARTIAL SEIZURE::SIMPLE PARTIALSIMPLE PARTIAL> produces sensory symptoms accompanied by motor that > produces sensory symptoms accompanied by motor that are localized or confined to a specific area.are localized or confined to a specific area.> client remains conscious and report an aura > client remains conscious and report an aura > with autonomic symptoms > with autonomic symptoms > with special sensory and somatosensory symptoms.> with special sensory and somatosensory symptoms.COMPLEX PARTIALCOMPLEX PARTIAL> with impairment of consciousness only.> with impairment of consciousness only.> a psycho motor seizure.> a psycho motor seizure.> characterized by periods of altered behavior that the client > characterized by periods of altered behavior that the client is not aware of.is not aware of.>the client loses of consciousness for a few seconds.>the client loses of consciousness for a few seconds.  

ASSESSMENT:ASSESSMENT: seizure historyseizure history type of seizuretype of seizure occurrence before, during, before and after seizure.occurrence before, during, before and after seizure. Prodomal signs, such as mood changes, irritability, Prodomal signs, such as mood changes, irritability,

insomnia.insomnia. Aura, a sensation that warns the client of the impeding Aura, a sensation that warns the client of the impeding

seizure. seizure. Loss of motor activity, or bowel and bladder function, or Loss of motor activity, or bowel and bladder function, or

loss of consciousness, during the seizure.loss of consciousness, during the seizure.

NURSING MANAGEMENT:NURSING MANAGEMENT: document events leading to an occurring during the document events leading to an occurring during the

seizure and to prevent complications.seizure and to prevent complications. Patient risk for hypoxia, vomiting, and pulmonary Patient risk for hypoxia, vomiting, and pulmonary

aspiration. To prevent complications, patient is placed on aspiration. To prevent complications, patient is placed on side-lying position to facilitate drainage or oral secretions side-lying position to facilitate drainage or oral secretions and is suctioned.and is suctioned.

Maintain patent airway.Maintain patent airway. Bed placed in low position and side rails up.Bed placed in low position and side rails up.  

PATHOPHYSIOLOGY:PATHOPHYSIOLOGY: massages the body are carried by the massages the body are carried by the

neuron of the brain by means of discharges neuron of the brain by means of discharges of electrochemical energy that swept along of electrochemical energy that swept along them.them.

During the period of unwanted discharges, During the period of unwanted discharges, parts of the body controlled by the errant parts of the body controlled by the errant cells may perform erratically.cells may perform erratically.

When these uncontrolled, abnormal When these uncontrolled, abnormal discharges occur repeatedly, a person is discharges occur repeatedly, a person is said to have an epileptic syndrome.said to have an epileptic syndrome.

People with epilepsy without other brain or People with epilepsy without other brain or nervous system disabilities fall within the nervous system disabilities fall within the same intelligence ranges as the overall same intelligence ranges as the overall population.population.

MEDICAL MANAGEMENT:MEDICAL MANAGEMENT:

CARBAMAZEPINE (TEGRETOLCARBAMAZEPINE (TEGRETOL)) > drug of choice for treatment of partial > drug of choice for treatment of partial

seizuresseizures > also been used for treatment of tonic-clonic > also been used for treatment of tonic-clonic

seizures and trigeminal neuralgia.seizures and trigeminal neuralgia. GABAPENTIN (NEURONTIN)GABAPENTIN (NEURONTIN) >used as adjunctive therapy in treatment of >used as adjunctive therapy in treatment of

focal seizures.focal seizures. LAMOTRIGINE(LAMICTAL)LAMOTRIGINE(LAMICTAL) >for focal seizures.>for focal seizures. > toxic effects is Steven-Johnson syndrome.> toxic effects is Steven-Johnson syndrome. TIAGABINE (GABITRIL)TIAGABINE (GABITRIL) > which is relatively a new drug that is used as > which is relatively a new drug that is used as

adjunctive therapy of partial seizure.adjunctive therapy of partial seizure.  

INTERVENTIONS:INTERVENTIONS: maintain patent AIRWAYmaintain patent AIRWAY administer oxygenadminister oxygen prepare to suctionprepare to suction turn the clients head to side.turn the clients head to side. Prevent injury during the seizurePrevent injury during the seizure remain with the clientremain with the client loosen restrictive clothingloosen restrictive clothing monitor for incontinencemonitor for incontinence document the character of the seizuredocument the character of the seizure instruct the client to avoid alcohol, instruct the client to avoid alcohol,

excessive stress and fatigue.excessive stress and fatigue.

HEADACHEHEADACHE

DEFINITION:DEFINITION:►headache or cephalgia; one of the headache or cephalgia; one of the

most common of all human physical most common of all human physical complaints.complaints.

►Headache is a symptom rather a Headache is a symptom rather a disease entity.disease entity.

►It may indicate organic disease It may indicate organic disease (neurologic or other disease), a stress (neurologic or other disease), a stress response, vasodilatation( migraine), response, vasodilatation( migraine), skeletal muscle tension, (tension skeletal muscle tension, (tension headache) or a combination of headache) or a combination of factors.factors.

I.PRIMARY HEADACHEI.PRIMARY HEADACHE> one for which no organic cause can be identified. > one for which no organic cause can be identified.

Types of headache include migraine, tension-type, Types of headache include migraine, tension-type, and cluster headache.and cluster headache.

► MIGRAINEMIGRAINE > a vascular disturbance that occurs > a vascular disturbance that occurs more commonly in woman.more commonly in woman.

> a symptom complex characteristics > a symptom complex characteristics periods and recurrent attacks of severe headaches.periods and recurrent attacks of severe headaches.

► TENSION HEADACHETENSION HEADACHE > more chronic than severe > more chronic than severe and are probably the most common type of and are probably the most common type of headache.headache.

► CLUSTER HEADACHECLUSTER HEADACHE > are severe form of vascular > are severe form of vascular headache.headache.

> seen five times more > seen five times more frequently in men than in women.frequently in men than in women.

► CRANIAL ARTERITISCRANIAL ARTERITIS> cause of headache in the > cause of headache in the older population, reaching its greatest incidence in older population, reaching its greatest incidence in those older than 70 years old of age.those older than 70 years old of age.

II. II. SECONDARY HEADACHE > a symptom associated SECONDARY HEADACHE > a symptom associated with an organic cause, such as brain tumor, or an with an organic cause, such as brain tumor, or an aneurysm.aneurysm.

> serious disorders related to headaches include > serious disorders related to headaches include brain tumor, subarrachnoid hemorrhage, stroke, brain tumor, subarrachnoid hemorrhage, stroke, severe hypertension, meningitis or head injury.severe hypertension, meningitis or head injury.

ASSESSMENT:ASSESSMENT:► detailed historydetailed history► physical assessment of head and neck and a complete physical assessment of head and neck and a complete

neurologic examination.neurologic examination.► May manifest differently within an individual over the course of May manifest differently within an individual over the course of

a lifetime of headache may present differently from patient to a lifetime of headache may present differently from patient to patient.patient.

► Sleep patter and level of stress.Sleep patter and level of stress.► Recreational interests and appetiteRecreational interests and appetite► emotional problemsemotional problems► family stressorsfamily stressors► headache's frequency, location and durationheadache's frequency, location and duration► type of paintype of pain

DIAGNOSTIC TESTS:DIAGNOSTIC TESTS:► CT scanCT scan► cerebral angiographycerebral angiography► MRIMRI► ElectromyographyElectromyography

LABORATORY TESTS:LABORATORY TESTS:► CBCCBC► erythrocyte sedimentation rateerythrocyte sedimentation rate► electrolyteselectrolytes► glucoseglucose► creatininecreatinine► thyroid hormone levelsthyroid hormone levels

PHATOPHYSIOLOGY:PHATOPHYSIOLOGY:► the cerebral signs and symptoms of migraine may the cerebral signs and symptoms of migraine may

result from dysfunction of the brain stem pathways result from dysfunction of the brain stem pathways that normally modulate sensory input.that normally modulate sensory input.

► Headache is preceded by risk in plasma serotonin, Headache is preceded by risk in plasma serotonin, which dilates the cerebral vessels, but migraines are which dilates the cerebral vessels, but migraines are more than just vascular headaches.more than just vascular headaches.

► Migraines can be triggered by menstrual cycles, Migraines can be triggered by menstrual cycles, bright lights, stress, depression, sleep deprivation, bright lights, stress, depression, sleep deprivation, fatigue, overuse of certain glutamate, nitrates or fatigue, overuse of certain glutamate, nitrates or milk products.milk products.

► Emotional or physical stress may cause contraction Emotional or physical stress may cause contraction of the muscles in the neck and scalp, resulting in of the muscles in the neck and scalp, resulting in tension headache.tension headache.

► Cranial arteritis is thought to represent an immune Cranial arteritis is thought to represent an immune vasculitis in which immune complexes are deposited vasculitis in which immune complexes are deposited within the walls of the affected blood vessels.within the walls of the affected blood vessels.

CLINICAL MANIFESTATIONS:CLINICAL MANIFESTATIONS:I.MIGRAINEI.MIGRAINEPRODOME PHASEPRODOME PHASE: depression, irritability, feeling cold, : depression, irritability, feeling cold, food cravings, anorexia, change in activity level, food cravings, anorexia, change in activity level, increase urination, diarrhea, constipation.increase urination, diarrhea, constipation.AURA PHASEAURA PHASE: characterize by focal neurologic : characterize by focal neurologic symptoms, visual disturbances, numbness and symptoms, visual disturbances, numbness and tingling of face and lips, hand, mild confusion, slight tingling of face and lips, hand, mild confusion, slight weakness of extremity, drowsiness, dizziness.weakness of extremity, drowsiness, dizziness.HEADACHE PHASE:HEADACHE PHASE: a vasodilatation and a decline in a vasodilatation and a decline in serotonin level occur, a throbbing headache over serotonin level occur, a throbbing headache over several hours. Severe anticipating; associated with several hours. Severe anticipating; associated with photo phobia, nausea and vomiting.photo phobia, nausea and vomiting.RECOVERY PHASERECOVERY PHASE: pain gradually subsides; muscle in : pain gradually subsides; muscle in the neck and scalp; muscle ache, localized the neck and scalp; muscle ache, localized tenderness, exhaustion and mood changes.tenderness, exhaustion and mood changes.

II.TENSION PHASE:II.TENSION PHASE:·steady, constant feeling of pressure that usually ·steady, constant feeling of pressure that usually begins in forehead, temple or back of the neck.begins in forehead, temple or back of the neck.    III. CLUSTER HEADACHE:  III. CLUSTER HEADACHE:·are unilateral and come in clusters of one to 8 daily ·are unilateral and come in clusters of one to 8 daily with excruciating pain localized to eye and orbit with excruciating pain localized to eye and orbit radiating to the facial temporal regions.radiating to the facial temporal regions.·Pain accompanied by watering eye and nasal ·Pain accompanied by watering eye and nasal congestion.congestion.   IV. CRANIAL ARTERITIS IV. CRANIAL ARTERITIS·fatigue, malaise, weight lose and fever·fatigue, malaise, weight lose and fever·inflammation usually are present·inflammation usually are present·sometimes a tender swollen or nodular temporal ·sometimes a tender swollen or nodular temporal artery is visible.artery is visible.  

PREVENTION:PREVENTION:· avoid specific triggers· avoid specific triggers· medication therapy· medication therapy· avoid alcohols, nitrates, vasodilators, histamines.· avoid alcohols, nitrates, vasodilators, histamines.· Prophylactic medication therapy· Prophylactic medication therapy  

NURSING MANAGEMENT:NURSING MANAGEMENT:· · relieving painrelieving pain

· comfort measures such as quiet, dark environment, · comfort measures such as quiet, dark environment, elevation of head of bed to 30 degreeselevation of head of bed to 30 degrees

· treatment of antiemetics· treatment of antiemetics

· application of local heat or massage· application of local heat or massage

MEDICAL MANAGEMENT:MEDICAL MANAGEMENT:► DIHYDROERGOTAMINE (MIGRANOL)DIHYDROERGOTAMINE (MIGRANOL) >which can be used in the IM or IV form, or as a >which can be used in the IM or IV form, or as a

nasal spray.nasal spray.► ERGOTAMINE ERGOTAMINE > mainstay of migraine headache.> mainstay of migraine headache. > administered sublingually for rapid absorption.> administered sublingually for rapid absorption.► CAFERGOTCAFERGOT >very popular oral form, combines ergotamine with >very popular oral form, combines ergotamine with

caffeine to increase absorption from GI tract.caffeine to increase absorption from GI tract.► METHYSERGIDE( SANSERT)METHYSERGIDE( SANSERT) >which is not used for acute attacks but to prevent >which is not used for acute attacks but to prevent

attacks or to decrease the intensity and frequency attacks or to decrease the intensity and frequency of attacks.of attacks.

► TRYPTANS, SEROTONIN RECEPTOR ANTAGONISTTRYPTANS, SEROTONIN RECEPTOR ANTAGONIST >cause vasoconstriction, reduce inflammation and >cause vasoconstriction, reduce inflammation and

may reduce pain transmission.may reduce pain transmission.  

Anthony Toledo, MD, RNAnthony Toledo, MD, RN