Altered Intracranial Function

  1. Consciousness
    awareness of self and environment, responds appropriately to stimuli
  2. Alertness and Cognition Needed:
    1. Alertness depends on reticular activation system (RAS) stimulation in thalmus and upper brainstem

    2. Cognition is controlled by cerebral hemipsheres - thoughts, memory, perception, problem-solving, emotion

    3. Nurse should assess patient's behavior and response to stimuli
  3. Altered Level of Consciousness
    • - Changes in alterness and/or cognition, solving complex problems
    • *Neurologic: head injury, stroke
    • *Toxicologic: OD, ETOH
    • *Metabolic disorders: hypoxia, hypoglycemia

    • - Localized & systemic disorders also affect LOC
    • *Trauma, ICP, CVA, hematoma, infection, demyelinating disorders

    - Any condition that affects delivery of blood, O2, glucose to brain

    - Seizure activity affects LOC
  4. Assessment of Unconscious Patient
    • - Pattern of respiration (irregularities)
    • - Eye signs
    • - Abnormal posturing
    • - Reflexes
    • - Level of Responsiveness
    • - Assymetry
  5. Assessement
    VS & Breathing Patterns
    Changes - airway --> ETT
  6. Assessment
    Pupillary and Oculomotor Responses
    • Localized --> ipsilateral; systemic-->pupils = affected
    • Metabolic --> small, =reactive
    • Fixed, unresponsive to light -->dilated
    • Spontaneous/reflexive eye mvmt altered
    • Doll's eyes present/absent - passive head
  7. Assessment
    Motor responses norm to flaccid
    • Strong vs weak, note ubable to lift
    • Withdrawal, fimiacing - flexor response
    • Decorticate mvmt - flexion upper
    • Decerebrate posturing - adduction and rigid ext of upper and lower
    • Flaccidity follows - no response to stimulation
  8. Assessment
    Restlessness, confusion, forgetfulness, disorientation, agitation, poor problem-solving, any change

    As impairment progresses, more stimuli to elicit a response

    Alert --> difficult to arouse, agitated, confused, small pupils --> disorientated to time, place, person

    Continuous stimulation --> no response, pupils dilated
  9. Assessment
    Persistent Vegatative State
    Complete unawareness of self and enviornment, sleep/wake, chews, swallows, coughs - use Glascow Coma Scale
  10. Assessment
    Brain Death
    Permanent loss of fuction; unresponsive, absent motor and reflexes (no elecetro function for 6-24hrs)
  11. Nursing Diagnoses for Altered Function
    • Inefffective Airway Clearance
    • Risk for Aspiration
    • Risk for Impaired Skin Integrity
    • Risk for Injury
    • Impaired Physical Mobiliity
    • Risk for Altered Nutrition: less than body requirements
    • Risk for Infection
    • Altered Family Coping
  12. Nursing Interventions for Altered Function
    • Maintain airway
    • Protect the patient
    • Maintain fluid balance
    • Manage nutritional needs
    • Provide mouth care
    • Maintain skin and joint integrity
    • Preserve corneal integrity
    • Maintain thermoregulation
    • Prevent urinary retention
    • Promote bowel function
    • Provide sensory stimulation
    • Medication management
    • Meet family needs
  13. Labs and Diagnostics
    Glucose, electrolyes, osmolarity, BUN, creatinine, LFT's, ABG's, toxivology screen, CBC, LP

    CT, MRI, EEG, Brain scan, cerebral angiography, transcranial doppler
Card Set
Altered Intracranial Function
Altered Intracranial Function