Altered Level of Consciousness client is not oriented, does not follow commands, or needs persistent stimuli to achieve a state of alertness.
Coma- a clinical state of unarousable unresponsiveness in which there are no purposeful responses to internal or external stimuli. Akineticmutism- state of unresponsiveness to the environment in which the patient makes no voluntary movement Persistent vegetative state- a condition in which the unresponsive client resumes sleep-wake cycles after coma but is devoid of cognitive or affective mental function. Locked-in syndrome- tetraplegia with inability to speak, but vertical eye movement s and lid elevation remain intact and are used to indicate responsiveness.
The level of responsiveness and consciousness is the MOST important indicator of the patient’s condition.
The nurse assume responsibility for the client until the basic reflexes return and the patient becomes conscious and oriented. Therefore, the major nursing goal is to compensate for the absence of these protective reflexes.
If the client begins to emerge from unconsciousness, every measure that is available and appropriate in calming and quieting the client should be used.
Monitor electrolytes as these patients are prone to hypernatremia, hypoglycemia, and hypokalemia with diuretic usage.
Monitor hyperventilation to maintain CO2 levels at 25 - 35mm Hg to prevent vasodilation
Medical Management includes: Anticonvulsant therapy for seizures. Use of diuretics such as Mannitol 50% Dextrose solution if hypoglycemia is present and persistent. Surgical decompression - considered life saving measure - opening of the skull can lead to severe herniation
Specific Treatment Surgical removal of intracranial masses. b. Placement of extraventricular drain (temporary). c. Placement of VP shunt (usually permanent).
Seizure Disorders Seizures- episodes of abnormal motor, sensory, autonomic, or psychic activity that results from sudden excessive discharge from cerebral neurons
Epilepsy a group of syndromes characterized by unprovoked, uncontrolled, recurring seizures due to excessive firing of hyperexcitable neurons of the brain
Types of headache Primary headache- no organic cause ca be identified Migraine- a symptom complex characterized by periodic and recurrent attacks of severe headache lasting from 4-72H Tension-type- tend to be chronic and less severe Cluster- severe form of vascular headache
Assessment The diagnostic evaluation includes a detailed history, a PA of the head and neck, and a complete neurologic examination
Migraine Migraine with an aura: Phases: Prodrome Aura phase Headache phase Recovery phase