chapter 20 lo - jones & bartlett...

9/10/2012

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Altered Mental Status

Lesson Goal

Identify, approach, & care for patients with altered mental status or changes in level of consciousness

Lesson Objectives

Discuss importance of appropriate airway management in patient with altered mental status

Discuss approach & care of patient with altered mental status

Identify patient with altered mental status who has history of diabetes

Copyright © 2013 by Jones & Bartlett Learning, LLC, an Ascend Learning Company

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Lesson Objectives

Identify patient with altered mental status who is taking diabetic medications

Outline steps in caring for patient with altered mental status who has diabetes

Lesson Objectives

Outline characteristics of oral glucose: generic name, trade name, dosage forms, dose, method of administration, action & contraindications

Discuss assessment of and treatment approach for patient experiencing seizure

Lesson Objectives

Identify patient who may be experiencing stroke

Discuss role of medical direction in emergency care of patient with altered mental status

Explain rationale for administering oral glucose


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Altered mental status (AMS)

Level of consciousness (LOC)


Possible causes Hypoxia Respiratory problems Head trauma Poisoning Diabetes Syncope Seizures Stroke Central nervous system (CNS) or general body

infection


General initial care same regardless of cause: Proper patient positioning

Maintain airway

Oxygenation & ventilation

Maintain body temperature

Expeditious transport

ALS care if available

Consultation with medical control, if appropriate

Glucose administration, if cause is known & allowed in protocol, especially with diabetes


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Altered Level of Consciousness

Normal Awake, alert, able to converse appropriately

Assessment Person, place, time, event Patient’s baseline mental status

Patients with altered LOC need rapid evaluation & treatment

Assessment Tools

AVPU Alert

Verbal

Painful

Unresponsive

Glasgow Coma Scale

Eye opening4 Spontaneously3 To verbal command2 To pain1 No response

Verbal response5 Oriented and converses4 Disoriented and converses3 Inappropriate words2 Incomprehensible sounds1 No response

Motor response6 Obeys verbal commands5 Localizes painful stimulus4 Flexion—withdraws to painful stimulus3 Abnormal flexion to painful stimulus2 Abnormal extension to painful stimulus 1 No response


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Assessment

Combine mental status finding with other assessment findings

Abnormal VS may cause or be caused by AMS

Diabetes

Glucose provides energy

Insulin required for glucose to enter cells

Brain cannot store glucose, requires constant supply

Without constant perfusion with oxygenated blood containing glucose, brain cells begin to die within minutes

Diabetes

Hyperglycemia When insulin is inadequate, glucose remains in

blood & cannot enter cells

Hypoglycemia Too much insulin causes glucose to be used too

quickly, leaving inadequate glucose in blood


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Diabetes

Type I Pancreas produces little

or no insulin

Usually develops in childhood

Patient must take injected insulin

Type II Insufficient insulin or

faulty receptors

Adult onset

Associated with obesity

Controlled with diet, exercise, and/or oral medications

Assessment

Critical questions History of diabetes?

• Taking medication for it?

• Insulin or oral medication?

• Medication taken as scheduled?

Did you eat recently?

Any unusual activity or illness?

Hypoglycemia

Hypoglycemia develops quickly Can occur for several reasons:

• Regular dose of insulin without food

• Too much exercise

• Too much insulin or oral medication

• Illness


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Hyperglycemia

Too little insulin or faulty insulin receptors

Glucose cannot enter cells Blood glucose increases

Glucose may enter urine

Water follows glucose

Dehydration

Breakdown of fats leads to ketoacidosis

Signs & Symptoms

AMS Rapid pulse Deep, rapid respirations (hyperglycemia) Warm dry skin (hyperglycemia) Cool, moist skin (hypoglycemia) Nausea, vomiting Headache Seizure

Treatment

Check blood glucose level if allowed & possible

Hyperglycemia requires hospital treatment

Hypoglycemia requires increase in blood glucose level Food, drink, glucose gel

Monitor airway in patients with ↓ LOC


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Skill 20-1: Oral Glucose

1. Consult medical direction for authorization to administer oral glucose

2. Check patient's responsiveness & ability to swallow


3. Place glucose on tongue depressor; administer full tube between patient's cheek & gum, allowing mucous membranes to absorb glucose

4. Reassess patient; document time of administration & any changes in patient condition


Video Clip coming soon


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Syncope

Temporary loss of consciousness

Caused by ↓ blood flow to brain Rapidly changing positions

Dilation of blood vessels

↓ cardiac output

Signs & Symptoms

Patient may be recovering on EMS arrival

Preceding symptoms Lightheadedness or dizziness

Tunnel vision

Nausea

Pale, cool, moist skin

Abnormal heart rate or respirations

Numbness or tingling of extremities

Treatment

Supine position Consider causes Evaluate for injuries if patient fell Loosen tight clothing Administer O2 if appropriate ↑ heart rate may indicate hypovolemia Call for ALS if patient is elderly or cardiac

problems are suspected Transport for evaluation


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Seizures

Abnormal electrical activity in brain

Depending on how brain is affected, seizure may include: Full body seizure

Seizure of isolated body parts

Staring into space

Bizarre behavior

Causes of Seizures

Fever

Infection

Hypoglycemia

Hypoxia

Head injury

Epilepsy

Types of Seizures

Partial Simple

Complex

Generalized

Absence


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Signs & Symptoms

Possible aura

Loss of consciousness

Loss of bladder/bowel control

May last several minutes

May be followed by AMS

Treatment

Protect patient from injury

Recovery position

Do not place anything in patient’s mouth

Provide O2

ALS for prolonged seizures

Transport

Stroke

3rd leading cause of death

Can lead to permanent disability

Caused by interruption of blood flow to brain Ischemic

Hemorrhagic

Signs & symptoms depend on area of brain deprived of blood flow


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Transient Ischemic Attack

Stroke symptoms last from few minutes to hours due to reduced blood flow to an area of the brain

TIA—warning sign of impending stroke

TIA patients must be evaluated at hospital

Thrombolytics

Some patients with ischemic stroke can be treated with thrombolytic drugs

Treatment must take place within specified period after stroke onset

Transport to designated stroke center when possible

Signs & Symptoms

Sudden behavior change

AMS

Difficulty speaking

Numbness or tingling

Facial droop

Vision changes

Pupil differences

Difficulty swallowing


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Treatment

Recognize signs & symptoms!

Provide supportive care ABCs, O2

Talk to patient

Make patient comfortable

Request ALS if available

Stroke Centers

EMS systems may have specifically designated stroke centers where patients can receive rapid assessment, diagnosis, & treatment

Summary

Many conditions can cause AMS

Use structured approach to assessment & treatment

Provide stabilizing care

Transport


chapter 20 lo - jones & bartlett...

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