neuro dysfunctions
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Neurologic Dysfunctions
Altered Level of Consciousness
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Altered Level of Consciousness
• Patient who is not oriented, does not followcommands, or needs persistent stimuli to a
state of alertness.
• Level of responsiveness and consciousness
important indicator of the patient's condition• Altered LOC is not a disorder but the result
pathology
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Altered Level of Consciousness (LO
• LOC is a continuum from normal alertness and full cognition (conscio
• Coma:
• unconsciousness, unarousable, unresponsiveness
• Akinetic mutism:
• unresponsiveness to the environment, makes no movement or sou
sometimes opens eyes
• Persistent vegetative state:
• devoid of cognitive function but has sleep-wake cycles• Locked-in syndrome:
• inability to move or respond except for eye movements due to a le
pons
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Pathology
• Underlying cause
• disruption in the cells of the nervous syst
neurotransmitters, or brain anatomy
• Disruptions result from cellular edema or
mechanisms, such as disruption of chem
transmission at receptor sites by antibodi
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Pathophysiology
• Due to multiplepathophysiologic
causes
• Head injury
• Toxicological: OD,ETOH intoxication
• Metabolic: Hepatic,
renal or DKA
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Clinical Manifestations
• Subtle behavioral changes [INITIALLY]
• Restlessness or increased anxiousness
• Pupillary changes
• Sluggish
• Fixed and Nonresponsive if in comatose state
• Coma
• Glascow coma scale <7: does not open eyes
spontaneously, nonverbal responses, no move
extremities
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Assessment and Diagnosis
• Complete H&P: emphasis on neurological s
• Evaluate mental status, cranial nerves, cere
function [balance and coordination], reflexe
motor and sensory function
• LOC
• Indicator of neuro function
• Assess based on Glasgow Coma Scare
• Eye opening, verbal response, motor response
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Glasgow Coma Scale
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Assessment/Diagnostics
• Common diagnostic procedures used to idecause of unconsciousness include
• Computed tomography (CT) scanning,
• Magnetic resonance imaging (MRI), and
• Electroencephalography (EEG).
• Less common procedures include
• Positron emission tomography (PET) and
• Single photonemission computed tomography
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Assessment/Diagnostics• Blood glucose,
• Electrolytes [BMP]• Serum ammonia, and liver function tests [LF
• Blood urea nitrogen (BUN)/Creatinine levels
osmolality; calcium level
• Coagulations studies: partial thromboplastinprothrombin times.
• Other studies may be used to evaluate seru
alcohol and drug concentrations, and arteria
gases.
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Medical Management
• Obtain & maintain patent airway: 1ST PRIOR
• Possible intubation and vented
• Monitor cardiovascular system to ensure pe
adequate
• Neuro care• Nutrititional care if indicated
• IV access
• Pharmacologic management as indicated
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Nursing Process: The Care of the Patient with Altered
Level of Consciousness — Assessment
• Assess verbal response and orientation
• Alertness
• Motor responses
• Respiratory status
• Eye signs• Reflexes
• Postures
• Glasgow Coma Scale
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Nurisng Diagnoses
• Ineffective airway clearance• Risk of injury
• Deficient fluid volume
• Impaired oral mucosa
• Risk for impaired skin integrity and impaired tissu
integrity (cornea)• Ineffective thermoregulation
• Impaired urinary elimination and bowelincontinence
• Disturbed sensory perception
• Interrupted family processes
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Potential Complications
• Respiratory distress or failure
• Pneumonia
• Aspiration
• Pressure ulcer
• Deep vein thrombosis (DVT)
• Contractures
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Planning and Goals
• Goals may include:• Maintenance of clear airway• Protection from injury• Attainment of fluid volume balance• Maintenance of skin integrity• Absence of corneal irritation
• Effective thermoregulation• Accurate perception of environmental stimuli• Maintenance of intact family or support system• Absence of complications
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Nursing Interventions
• A major nursing goal is to compensate for the patient's losreflexes and to assume responsibility for total patient care
also includes maintaining the patient’s dignity and privacy
• Maintaining an airway
• Frequent monitoring of respiratory status including aus
lung sounds• Positioning to promote accumulation of secretions and
obstruction of upper airway—HOB elevated 30°, latera
position
• Suctioning, oral hygiene, and CPT
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Skin Integrity
• Assess skin frequently, especially areas with high potentia
breakdown• Frequent turning; use turning schedule
• Careful positioning in correct body alignment
• Passive ROM
• Use of splints, foam boots, trochanter rolls, and specialty
needed• Clean eyes with cotton balls moistened with saline
• Use artificial tears as prescribed
• Measures to protect eyes; use eye patches cautiously as
may contact patch
• Frequent, scrupulous oral care
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Nursing Interventions
• Maintaining fluid status• Assess fluid status by examining tissue turgor and muc
and I&O.
• Administer IVs, tube feedings, and fluids via feeding tu
required—monitor ordered rate of IV fluids carefully.
• Maintaining body temperature• Adjust environment and cover patient appropriately.
• If temperature is elevated, use minimum amount of bed
administer acetaminophen, use hypothermia blanket, g
sponge bath, and allow fan to blow over patient to incre
• Monitor temperature frequently and use measures to p
shivering.
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Nursing Interventions: Bowel & Bla
• Assess for urinary retention and urinary inc• May require indwelling or intermittent cathe
• Bladder-training program
• Assess for abdominal distention, potentialconstipation, and bowel incontinence
• Monitor bowel movements
• Promote elimination with stool softeners, glysuppositories, or enemas as indicated
• Diarrhea may result from infection, medicathyperosmolar fluids
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Nursing Interventions: Sensory &
Communication
• Talk to and touch patient and encourage family totouch the patient
• Maintain normal day night pattern of activity
• Orient the patient frequently
• Note: When arousing from coma, a patient may eperiod of agitation; minimize stimulation at this tim
• Programs for sensory stimulation
• Allow family to ventilate and provide support
• Reinforce and provide and consistent information
• Referral to support groups and services for family
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Nursing Alert
• If the patient begins to emerge from unconsness, every measure that is available and a
for calming and quieting the patient should
Any form of restraint is likely to be countere
resistance, leading to self-injury or to a danincrease in ICP. Therefore, physical restrain
be avoided if possible; a written prescription
obtained if their use is essential for the patie
being.
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Nursing Alert
• The body temperature of an unconscious pnever taken by mouth.
• Rectal or tympanic (if not con-traindicated)
temperature measurement is preferred toth
accurate axillary temperature.
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Abnormal Posturing
• Response to noxious stimuli: Flaccidity with
of motor response
• Decorticate posture (flexion and internal r
forearms and hands)
• Seen with cerebral hemisphere pathology and
depression of brain function
• Decerebrate posture (extension and exter
rotation)
• deeper and more severe dysfunction than does
posturing; implies brain pathology; poor progn