chamberlain college of nursing nr603 week 1 study guide nr 603 week 1 study guide new
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CHAMBERLAIN COLLEGE OF NURSING
NR603 (NR603)
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NR 603 Week 1 Study Guide
Migraine: Assessment
It is important that the patient characterize the headache by describing the duration, quality,
and location of the pain.
A medication profile is essential and should include medications that have been tried in the
past for headache control. If OTC medications are taken, the number used per month should
be identified
A targeted physical examination is important in ruling out harmful secondary headache
pathologies and confirms any information given in the history.
The examination findings in primary headache disorders are usually within normal limits.
Key aspects of the physical examination include a cardiopulmonary and complete
neurologic assessment with a major focus on the following:
· • Funduscopic and pupillary assessment
· • Auscultation of the carotid and vertebral arteries
· • Mental status examination
· • Palpation of the head, neck, and temporal arteries
· • Evaluation for any neck stiffness, focal weakness, sensory loss and gait
· • Vital signs
Problem findings include:
· Onset of headache after the age of 50 years
· Asymmetry of pupillary responses
· Decreased deep tendon reflexes
· Headache described as “the worst ever experienced”
· Personality change
· Onset of a new or different headache
· Onset of a headache that progressively worsens
· Papilledema
· Painful temporal arteries
Diagnosis
· If the diagnosis is not clear or the history or physical findings are cause for concern,
diagnostic studies should be used to distinguish primary headache from a secondary
condition.
· Blood tests are usually not indicated, may include a complete blood count (CBC) to
exclude anemia or an infectious process, (ESR) or (CRP) to help exclude temporal
arteritis, and thyroid function tests to identify thyroid dysfunction.
· Lyme titer or rheumatoid factors may also be indicated in some situations.
Practice guidelines
· Advocate three principles for diagnostic testing:
(1) testing should be avoided if it will not change the management of the
patient,
(2) testing is not indicated if the patient is not significantly more likely than the
general public to have an abnormality
(3) testing may make sense in a patient who is excessively concerned that he
or she has a serious problem that is causing the headaches.
· Neuroimaging should be considered when any serious signs or symptoms are present
but it is not indicated if the patient has had these headaches for years, if there are no
focal neurologic signs, and if the headache improves without the use of analgesics.
, Treatment
· Nonpharmacological measures
behavior modification, biofeedback, acupressure, management of headache
triggers, and a wellness program.
· Preventive therapy is appropriate for patients if they are unable to deal with their
attacks, they experience more than four headaches a month, or the attacks are
prolonged and refractory to medicine.
Preventive therapy is given daily and will decrease headache intensity and
frequency
A connection has been shown between epilepsy and migraine; therefore
anticonvulsants, such as divalproex sodium (Depakote), gabapentin
(Neurontin), and topiramate (Topamax), can be used
A patient with cold hands, Raynaud phenomenon, or hypertension may do well
with calcium channel blockers, such as diltiazem (Cardizem) and amlodipine
(Norvasc), which cause vasodilation and decrease blood pressure.
A beta blocker, such as propranolol (Inderal) or atenolol, may be chosen for the
patient with palpitations caused by mitral valve prolapse or panic disorders and
should be avoided in those with asthma.
If sleep is a problem or if chronic pain persists in the shoulders, a tricyclic
antidepressant, such as amitriptyline (Elavil).
The mechanism of action for both beta blockers and calcium channel
blockers is not fully understood.
Calcium channel blockers prevent calcium from entering the cells and
therefore decrease their excitability. This may in turn prevent vascular
spasm and headache.
Beta blockers affect the beta1-adrenergic receptors and inhibit the usual
adrenergic responses.
it has been theorized that either may have an effect on the serotonergic
system within the brain and the vascular system.
· Abortive therapy is used to treat the intensity and duration of pain during an attack
and to manage associated symptoms, such as nausea and vomiting
A patient with a severe migraine or cluster attack that peaks to full intensity
within 15 minutes will most likely benefit from parenteral or nasal therapy
rather than oral medication
Simple analgesics, such as acetaminophen and aspirin, can represent first-
line treatment in the management of mild to moderate headaches.
Caffeine combinations (Excedrin, Anacin) can potentiate their absorption
and analgesia.
When simple analgesics are ineffective, combining them with a short-
acting barbiturate, such as butalbital (Fioricet, Fiorinal, Esgic), may be
effective.
(NSAIDs) are helpful in treating an acute attack.
Naproxen sodium (Anaprox DS, Aleve) has a longer half-life and a better
safety profile than some of the other NSAIDs. The addition of
metoclopramide will facilitate their absorption and potentiate their effect.
Ergot derivatives are effective in the treatment of moderate to severe attacks
that might not have responded to simple or combination analgesics. Two forms
are currently in use: ergotamine tartrate (Cafergot) and dihydroergotamine.
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