NURSING 465 - Alterations in Neurological Function. Complete Study Guide 2021.

Document Content and Description Below

Alterations in Neurological Function Altered Level of Consciousness (LOC) • Level of responsiveness and consciousness is the most important indicator of the patient's condition • LOC is a cont ... inuum from normal alertness and full cognition (consciousness) to coma • Altered LOC is not the disorder but the result of a pathology • Coma: unconsciousness, unarousable unresponsiveness (responding inappropriately is not coma) • Akinetic mutism: unresponsiveness to the environment, makes no movement or sound but sometimes opens eyes - cant make a physical movement in response to the env’t • Persistent vegetative state: devoid of cognitive function but has sleep–wake cycles - they just don’t respond in normal ways- cant understand or respond to language • Locked-in syndrome: inability to move or respond except for eye movements due to a lesion affecting the pons (cant respond bc of a lesion affecting the pons. Can communicate with eye movements)- “fully alive in your mind” as opposed to Akinetic mutism • Most important thing to think about with Neuro is LOC • Most important indicator- tells us about neurological fcn (whether its CVA, diabetic neuropathy, etc.) • On a continuum-ex. A&O x3 • Its how we assess a patient • Review GCS- Know cut offs • Are they able to respond and if they can respond are they responding appropriately? • Orientation: Who your are. When it is in time. The Care of the Patient With Altered Level of Consciousness • Assess verbal response and orientation • Alertness (are they looking around spontaneously?) • Motor responses – fine and gross • Fine • Feed themselves • Pick up a pencil • Gross motors • Push against (resistance), etc. • Respiratory status • May have a decrease is respiratory status ECHO • Eye signs • ECHO • Reflexes • Pain, touch (light, pressure, etc.) • Postures • Glasgow Coma Scale Should you re- orient pt who is not A&O x3? If there’s a physical pathology that’s preventing them from retaining the year month or day- then no. They must be able to grasp the information and it must be productive. Ex. someone having delirium or med. Rxn- then maybe Collaborative Problems and Potential Complications ECHO • Respiratory distress or failure • Pneumonia • Aspiration • Pressure ulcer • Deep vein thrombosis (DVT) • Contractures • Pts with RD or RF can have altered LOC • Most imp thing to do as nurses it to help our pt. compensate (ex. turning and positioning for pts that lack the ability to shift (to prevent PU)) Interventions ECHO • A major nursing goal is to compensate for the patient's loss of protective reflexes and to assume responsibility for total patient care. Protection also includes maintaining the patient’s dignity and privacy. • Maintaining an airway • Frequent monitoring of respiratory status, including auscultation of lung sounds • Positioning to promote accumulation of secretions and prevent obstruction of upper airway—head of bed (HOB) elevated 30 degrees; lateral or semiprone position • Suctioning, oral hygiene, and CPT • CAB- cardiac, airway, breathing Maintaining Tissue Integrity • Assess skin frequently, especially areas with high potential for breakdown • Frequent turning; use turning schedule • Careful positioning in correct body alignment (esp pts with spinal alignments, CVAs who have a weak side) • Passive ROM (prevents contractures- maintains fcn) • Breakdown in neuro fcn causes contraction • Use of splints, foam boots, trochanter rolls, and specialty beds as needed • Its your responsibility to figure out if mattress is appropriately • MD orders it though • Clean eyes with cotton balls moistened with saline • Use artificial tears as prescribed • Might need to close and keep eyes close • May use eye patches- not used as much- because pts can open they’re eyes underneath which results in corneal scratching from the patch • Measures to protect eyes; use eye patches cautiously because the cornea may contact patch [Show More]

Last updated: 3 years ago

Preview 1 out of 19 pages