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Consciousness
awareness of self and environment, responds appropriately to stimuli
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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
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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
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Assessment of Unconscious Patient
- - Pattern of respiration (irregularities)
- - Eye signs
- - Abnormal posturing
- - Reflexes
- - Level of Responsiveness
- - Assymetry
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Assessement
VS & Breathing Patterns
Changes - airway --> ETT
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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
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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
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Assessment
Arousal/Alertness
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
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Assessment
Persistent Vegatative State
Complete unawareness of self and enviornment, sleep/wake, chews, swallows, coughs - use Glascow Coma Scale
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Assessment
Brain Death
Permanent loss of fuction; unresponsive, absent motor and reflexes (no elecetro function for 6-24hrs)
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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
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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
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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
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