Headache </li></li></ul><li>Altered Level of Consciousness <br />client is not oriented, does not follow commands, or needs persistent stimuli to achieve a state of alertness.<br />
Coma- a clinical state of unarousable unresponsiveness in which there are no purposeful responses to internal or external stimuli. <br />Akineticmutism- state of unresponsiveness to the environment in which the patient makes no voluntary movement<br />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. <br />Locked-in syndrome- tetraplegia with inability to speak, but vertical eye movement s and lid elevation remain intact and are used to indicate responsiveness. <br />
The level of responsiveness and consciousness is the MOST important indicator of the patient’s condition.<br />
Interrupted family processes</li></li></ul><li>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. <br />
If the client begins to emerge from unconsciousness, every measure that is available and appropriate in calming and quieting the client should be used. <br />
Nursing Interventions <br /><ul><li>Maintaining the airway
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</li></li></ul><li>Medical Management includes:<br />Anticonvulsant therapy for seizures.<br />Use of diuretics such as Mannitol<br />50% Dextrose solution if hypoglycemia is present and persistent.<br />Surgical decompression<br />- considered life saving measure<br />- opening of the skull can lead to severe herniation<br />
Specific Treatment<br />Surgical removal of intracranial masses.<br />b. Placement of extraventricular drain (temporary).<br />c. Placement of VP shunt (usually permanent).<br />
Seizure Disorders <br />Seizures- episodes of abnormal motor, sensory, autonomic, or psychic activity that results from sudden excessive discharge from cerebral neurons <br />
Epilepsy <br />a group of syndromes characterized by unprovoked, uncontrolled, recurring seizures due to excessive firing of hyperexcitable neurons of the brain<br />
International Classification of Seizures <br />
Push aside any furniture that may injure the patient during the seizure
If the patient in in bed, remove the pillows and raise all side rails
In an aura precedes the seizure, insert an oral airway
DO NOT ATTEMPT TO PRY OPEN JAWS THAT ARE CLENCHED IN A SPASM OR TO INSERT ANYTHING.
No attempt should be made to restrain the patient during the seizure
If possible, place the patient on one side with head flexed forward. </li></li></ul><li>After a Seizure <br />The nurse’s role is to document the events leading to and occurring during and after the seizure and to prevent complications <br />
Nursing care after the seizure <br /><ul><li>Keep the patient on one side------Make sure the airway is patent
The patient, on awakening, should be reoriented to the environment
If the patient becomes agitated after a seizure, use a calm persuasion and gentle restraints. </li></li></ul><li>Nursing diagnoses <br /><ul><li>Risk for injury
Monitoring and managing potential complications
Promoting home and community based care </li></li></ul><li>Status Epilepticus<br />A series of generalized seizures that occur without full recovery of consciousness between attacks <br />
Medical management <br />The goals of treatment are to stop the seizures as quickly as possible, to ensure adequate cerebral oxygenation, and to maintain the patient in a seizure-free state <br />
Most common of all human physical complaints </li></li></ul><li>Types of headache <br />Primary headache- no organic cause ca be identified <br />Migraine- a symptom complex characterized by periodic and recurrent attacks of severe headache lasting from 4-72H<br />Tension-type- tend to be chronic and less severe <br />Cluster- severe form of vascular headache <br />
Assessment <br />The diagnostic evaluation includes a detailed history, a PA of the head and neck, and a complete neurologic examination<br />
Migraine <br />Migraine with an aura: <br />Phases: <br />Prodrome<br />Aura phase<br />Headache phase<br />Recovery phase <br />
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