This document discusses the management of patients with neurologic dysfunction and altered levels of consciousness. It defines altered LOC as being less responsive to the environment. Causes can be structural, metabolic, or due to trauma, vascular disease, infection, tumors, metabolic derangements, hypoxia, or toxicity. Clinical manifestations range from subtle changes to coma. Nursing assessments include responsiveness, orientation, motor function and respiratory status. Interventions focus on airway protection, injury prevention, meeting fluid and nutrition needs, and skin and sensory integrity.
Craniotomy
A craniotomy involves making an incision in the scalp and creating a hole known as a bone flap in the skull. The hole and incision are made near the area of the brain being treated.
During open brain surgery, it is done to remove tumors, clip off an aneurysm, drain blood or fluid from an infection & remove abnormal brain tissue
Decompressive craniectomy
It is a neurosurgical procedure in which part of the skull is removed to allow a swelling brain room to expand without being squeezed. It is performed on victims of traumatic brain injury, stroke and other conditions associated with raised intracranial pressure.
Increased intracranial pressure is defined as cerebrospinal fluid pressure greater than 15 mm Hg.
Infections
Tumors
Stroke
Aneurysm
Epilepsy
Seizures
Hydrocephalus
Hypertensive brain injury
Hypoxemia
Meningitis
Due to etiological factors
Components of ICP is disturbed- brain tissue, CSF, blood volume
An increase in the volume of ANY ONE component must be accompanied by a reciprocal decrease in one of the other components.
When this volume-pressure relationship becomes unbalanced, ICP increases.
There are numerous types of brain surgery. The type used is based on the area of the brain and the condition being treated.
Brain surgery is a critical and complicated process. The type of brain surgery done depends highly on the condition being treated.
Intracranial surgery refers to various medical procedures that involve repairing structural problems in the brain.
Craniotomy
A craniotomy involves making an incision in the scalp and creating a hole known as a bone flap in the skull. The hole and incision are made near the area of the brain being treated.
During open brain surgery, it is done to remove tumors, clip off an aneurysm, drain blood or fluid from an infection & remove abnormal brain tissue
Decompressive craniectomy
It is a neurosurgical procedure in which part of the skull is removed to allow a swelling brain room to expand without being squeezed. It is performed on victims of traumatic brain injury, stroke and other conditions associated with raised intracranial pressure.
Definition of Triagea
Triage is the term derived from the French verb trier meaning to sort or to choose
It’s the process by which patients classified according to the type and urgency of their conditions to get the . Right patient to the
Right place at the
Right time with the
Right care provider
Craniotomy
A craniotomy involves making an incision in the scalp and creating a hole known as a bone flap in the skull. The hole and incision are made near the area of the brain being treated.
During open brain surgery, it is done to remove tumors, clip off an aneurysm, drain blood or fluid from an infection & remove abnormal brain tissue
Decompressive craniectomy
It is a neurosurgical procedure in which part of the skull is removed to allow a swelling brain room to expand without being squeezed. It is performed on victims of traumatic brain injury, stroke and other conditions associated with raised intracranial pressure.
Increased intracranial pressure is defined as cerebrospinal fluid pressure greater than 15 mm Hg.
Infections
Tumors
Stroke
Aneurysm
Epilepsy
Seizures
Hydrocephalus
Hypertensive brain injury
Hypoxemia
Meningitis
Due to etiological factors
Components of ICP is disturbed- brain tissue, CSF, blood volume
An increase in the volume of ANY ONE component must be accompanied by a reciprocal decrease in one of the other components.
When this volume-pressure relationship becomes unbalanced, ICP increases.
There are numerous types of brain surgery. The type used is based on the area of the brain and the condition being treated.
Brain surgery is a critical and complicated process. The type of brain surgery done depends highly on the condition being treated.
Intracranial surgery refers to various medical procedures that involve repairing structural problems in the brain.
Craniotomy
A craniotomy involves making an incision in the scalp and creating a hole known as a bone flap in the skull. The hole and incision are made near the area of the brain being treated.
During open brain surgery, it is done to remove tumors, clip off an aneurysm, drain blood or fluid from an infection & remove abnormal brain tissue
Decompressive craniectomy
It is a neurosurgical procedure in which part of the skull is removed to allow a swelling brain room to expand without being squeezed. It is performed on victims of traumatic brain injury, stroke and other conditions associated with raised intracranial pressure.
Definition of Triagea
Triage is the term derived from the French verb trier meaning to sort or to choose
It’s the process by which patients classified according to the type and urgency of their conditions to get the . Right patient to the
Right place at the
Right time with the
Right care provider
hii guys this is my ongoing presentation from my speciality class i hope u guys lije that please so i hope it is been useful for u in ur specialities by getting little help with that
A neurological examination is the assessment of sensory neuron and motor responses, especially reflexes, to determine whether the nervous system is impaired. This typically includes a physical examination and a review of the patient's medical history, but not deeper investigation such as neuroimaging.
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Synthetic Fiber Construction in lab .pptxPavel ( NSTU)
Synthetic fiber production is a fascinating and complex field that blends chemistry, engineering, and environmental science. By understanding these aspects, students can gain a comprehensive view of synthetic fiber production, its impact on society and the environment, and the potential for future innovations. Synthetic fibers play a crucial role in modern society, impacting various aspects of daily life, industry, and the environment. ynthetic fibers are integral to modern life, offering a range of benefits from cost-effectiveness and versatility to innovative applications and performance characteristics. While they pose environmental challenges, ongoing research and development aim to create more sustainable and eco-friendly alternatives. Understanding the importance of synthetic fibers helps in appreciating their role in the economy, industry, and daily life, while also emphasizing the need for sustainable practices and innovation.
Welcome to TechSoup New Member Orientation and Q&A (May 2024).pdfTechSoup
In this webinar you will learn how your organization can access TechSoup's wide variety of product discount and donation programs. From hardware to software, we'll give you a tour of the tools available to help your nonprofit with productivity, collaboration, financial management, donor tracking, security, and more.
2024.06.01 Introducing a competency framework for languag learning materials ...Sandy Millin
http://sandymillin.wordpress.com/iateflwebinar2024
Published classroom materials form the basis of syllabuses, drive teacher professional development, and have a potentially huge influence on learners, teachers and education systems. All teachers also create their own materials, whether a few sentences on a blackboard, a highly-structured fully-realised online course, or anything in between. Despite this, the knowledge and skills needed to create effective language learning materials are rarely part of teacher training, and are mostly learnt by trial and error.
Knowledge and skills frameworks, generally called competency frameworks, for ELT teachers, trainers and managers have existed for a few years now. However, until I created one for my MA dissertation, there wasn’t one drawing together what we need to know and do to be able to effectively produce language learning materials.
This webinar will introduce you to my framework, highlighting the key competencies I identified from my research. It will also show how anybody involved in language teaching (any language, not just English!), teacher training, managing schools or developing language learning materials can benefit from using the framework.
The Art Pastor's Guide to Sabbath | Steve ThomasonSteve Thomason
What is the purpose of the Sabbath Law in the Torah. It is interesting to compare how the context of the law shifts from Exodus to Deuteronomy. Who gets to rest, and why?
How to Split Bills in the Odoo 17 POS ModuleCeline George
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Operation “Blue Star” is the only event in the history of Independent India where the state went into war with its own people. Even after about 40 years it is not clear if it was culmination of states anger over people of the region, a political game of power or start of dictatorial chapter in the democratic setup.
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2. Learning objectives:
• Define level of consciousness alteration
• Differentiate between level of consciousness
alterations
• Identify the pathophysiology of altered level of
consciousness
• Identify the clinical manifestation and
complication of patient with altered level of
consciousness
• Describe the multiple needs of the patient
with altered level of consciousness
• Use the nursing process as a framework for
care of the patient with altered level of
consciousness
3. Definition
• altered level of consciousness is defined
as a condition of being less responsive to
and aware of environmental stimuli.
• LOC is gauged on a continuum with a
normal state of alertness and full cognition
(consciousness) on one end and coma on
the other end.
4. Altered level of consciousness
terminology
• Alert or conscious: attends to the
environment, responds appropriately to
commands and questions with minimal
stimulation
• Confused: disoriented to surroundings,
may have impaired judgment, may
need cues to respond to commands
• Lethargic: drowsy, needs gentle verbal
or touch stimulation to initiate response
5. Continue
• Obtunded: responds slowly to external
stimulation, needs repeated stimulation to
maintain attention and response to the
environment
• Stuporous: responds only minimally with
vigorous stimulation, may only moan as a verbal
response
• Comatose: no observable response to any
external stimuli
7. Continue
2. Metabolic
• Systemic metabolic derangement: hypoglycaemia,
diabetic ketoacidosis, hyperglycaemic nonketotic
hyperosmolar state, uraemia, hepatic
encephalopathy, hyponatremia, myxedema
• Hypoxic encephalopathies: sever congestive heart
failure, chronic obstructive pulmonary disease,
sever anaemia, prolonged hypertension
• Toxicity: heavy metals, carbon monoxide,
drug(opiates, barbiturates and alcohol)
• Extremes of body temperature: heat stroke,
hypothermia
• Seizures
8. Pathophysiology
• Altered level of consciousness is a
symptom of a multiple pathophysiologic
causes such as:
• Neurologic: head injury, stroke
• Toxicologic: drug overdose, alcohol
intoxication
• Metabolic: hepatic failure, renal failure,
diabetic ketoacidosis
• The underlying causes of neurologic
dysfunction are disruption in the cells of
the nervous system, neurotransmitters, or
brain anatomy
9. Continue
1. Cellular brain edema or disrupting chemical
transmission at receptor site, result in faulty
impulse transmission and impeding
communication within the brain or from the
brain to other body parts
2. Brain trauma, brain edema, tumor pressure,
increase or decrease blood or cerebrospinal
fluid result in disruption in anatomic
structure of the brain and faulty impulse
transmission and impeding communication
within the brain or from the brain to other
body part
10. Clinical manifestations
• As the patient’s state of alertness and
consciousness decreases, there will be
changes in the pupillary response, eye
opening response, verbal response, and
motor response.
• Initial changes may be reflected by subtle
behavioral changes such as restlessness or
increased anxiety,with time,there will be
decrease wakefulness, decrease attention to
environment, confusion, disorientation,
agitation, poor memory, decrease ability to
carry out activities of daily living, decrease
mobility, incontinence, hallucination, and
delusions
11. Continue
• The pupils, normally round and quickly
reactive to light, become sluggish
(response is slower); as the patient
becomes comatose, the pupils become
fixed (no response to light).
• The patient in a coma does not open the
eyes, respond verbally, or move the
extremities.
12. Assessment and Diagnostic Findings
• Neurological examination, which includes an
evaluation of mental status, cranial nerve
function, cerebellar function (balance and
coordination), reflexes, and motor and
sensory function.
• Glasgow Coma Scale is used: eye opening,
verbal response, and motor response
The Glasgow Coma Scale is a tool for
assessing a patient’s response to stimuli.
Scores range from 3 (deep coma) to 15
(normal).
13. Glasgow Coma Scale
Eye opening response Spontaneous 4
To voice 3
To pain 2
None 1
Best verbal response Oriented 5
Confused 4
Inappropriate words 3
Incomprehensible sounds 2
None 1
Best motor response Obeys command 6
Localizes pain 5
Withdraws 4
Flexion 3
Extension 2
None 1
Total 3 to 15
14. Procedures used to identify the cause
of unconsciousness include
• Scanning
• Computed tomography
• Magnetic resonance imaging
• Positron emission tomography
• Eelectroencephalography
15. Laboratory tests include
• Blood glucose
• Electrolytes
• Serum ammonia
• Blood urea nitrogen
• Calcium level
• Partial thromboplastin and prothrombin
time
17. Medical management
• Obtain and maintain a patent airway.
• Intubation, or a tracheostomy may be
performed.
• Mechanical ventilator is used to
maintain adequate oxygenation.
• The circulatory status (blood
pressure, heart rate) is monitored to
ensure adequate perfusion to the
body and brain.
18. Continue
• An intravenous catheter is inserted
to provide access for fluids
• intravenous medications.
• Nutritional support, using either a
feeding tube or a gastrostomy tube
• Determine and treat the underlying
causes of altered LOC.
• Pharmacological management of
complications and strategies to
prevent complications.
20. Assessment
• Level of responsiveness or consciousness
• Verbal response.
• Patient’s orientation to time, person, and
place, the patient is asked to identify the day,
date, or season of the year and to identify
where he or she is or to identify the clinicians,
family members, or visitors present.
• Assess alertness by the patient’s ability to
open the eyes spontaneously or to a stimulus.
• Periorbital edema or trauma, which may
prevent the patient from opening the eyes.
21. Continue
• Motor response includes spontaneous,
purposeful movement, movement only in
response to noxious stimuli, or abnormal
posturing (decorticate or decerebrate).
• Respiratory status and pattern of respiration.
• Eye signs, and reflexes.
• Corneal reflex.
• Facial symmetry.
• Swallowing reflex.
• Deep tendon reflex.
22.
23. Nursing Diagnosis
• Ineffective airway clearance related to
altered level of consciousness.
• Risk of injury related to decreased level
of consciousness.
• Deficient fluid volume related to inability
to take in fluids.
• Impaired oral mucous membranes
related to mouth breathing, absence of
pharyngeal reflex, and altered fluid
intake.
• Risk for impaired skin integrity related to
immobility.
24. Continue
• Impaired tissue integrity of cornea related to
diminished or absent of corneal reflex.
• Ineffective thermoregulation related to
damage to hypothalamic center
• Impaired urinary elimination (incontinence or
retention) related to impairment in neurologic
sensing and control.
• Bowel incontinence related to impairment in
neurologic sensing and control.
• Disturbed sensory perception related to
neurologic impairment.
• Interrupted family processes related to health
crisis.
26. Maintaining the airway
• Remove accumulated secretion to eliminate
the danger of aspiration.
• Elevating the head of the bed to 30 degrees
helps prevent aspiration.
• Positioning the patient in a lateral or
semiprone position to promote drainage of
secretions.
• Suctioning and oral hygiene to remove
secretions from the posterior pharynx and
upper trachea.
• Hyperoxygenated and hyperventilated the
patient before and after suctioning to prevent
hypoxia
27. Continue
• Chest physiotherapy and postural drainage to
promote pulmonary hygiene.
• Auscultate the chest at least every 8 hours to
detect adventitious breath sounds or absence of
breath sounds.
• Maintaining the patency of the endotracheal tube
or tracheostomy for intubated patient.
• Providing frequent oral care.
• Monitoring arterial blood gas measurements.
28. Protecting the patient
• Padded side rails and raised at all times.
• prevent injury from invasive lines and equipment
(eg, restraints, tight dressings, environmental
irritants, damp bedding or dressings, tubes and
drains).
• protecting the patient’s dignity during altered
LOC as providing privacy and speaking to the
patient during nursing care activities to preserve
the patient’s humanity.
• No negative speaking about the patient’s
condition or prognosis in the patient’s presence.
29. MAINTAINING FLUID BALANCE AND
MANAGING NUTRITIONAL NEEDS
• Hydration status is assessed by examining
tissue turgor and mucous membranes.
• Assessing intake and output, and analyzing
laboratory data.
• Fluid needs are met initially by giving the
required fluids intravenously.
• intravenous solutions for patients with
intracranial conditions must be administered
slowly.
• Restrict fluid administration to minimize the
possibility of producing cerebral edema.
• Enteral feeding to the patient with inadequate
fluid and calories intake by mouth.
30. Providing mouth care
• The mouth is inspected for dryness,
inflammation, and crusting.
• Oral care because there is a risk of parotitis.
The mouth is cleansed and rinsed carefully to
remove secretions and crusts and to keep the
mucous membranes moist.
• A thin coating of petrolatum on the lips to
prevent drying, cracking, and encrustations.
• If the patient has an endotracheal tube, the
tube should be moved to the opposite side of
the mouth daily to prevent ulceration of the
mouth and lips.
31. MAINTAINING SKIN AND JOINT
INTEGRITY
• Continuing nursing assessment and
intervention.
• Special attention is given to unconscious
patients because they cannot respond to
external stimuli.
• Regular schedule of turning to avoid
pressure, which can cause breakdown and
necrosis of the skin.
• Turning also provides kinesthetic (sensation
of movement), proprioceptive (awareness of
position), and vestibular (equilibrium)
stimulation.
32. Continue
• After turning, the patient is carefully
repositioned to prevent ischemic necrosis
over pressure areas.
• Dragging the patient up in bed must be
avoided, because this creates a shearing
force and friction on the skin surface.
• Maintaining correct body position, passive
exercise of the extremities to prevent
contractures.
• Use of splints or foam boots aid in the
prevention of footdrop and eliminate the
pressure of bedding on the toes.
33. Continue
• Trochanter rolls supporting the hip joints
keep the legs in proper alignment.
• The arms should be in abduction, the
fingers lightly flexed, and the hands in
slight supination.
• The heels of the feet should be
assessed for pressure areas.
• Specialty beds, such as fluidized or low-
air-loss beds, may be used to decrease
pressure on bony prominences.
34. PRESERVING CORNEAL INTEGRITY
• The eyes may be cleansed with cotton balls
moistened with sterile normal saline to
remove debris and discharge.
• If artificial tears are prescribed, they may be
instilled every 2 hours.
• Periocular edema (swelling around the eyes)
often occurs after cranial surgery.
• Cold compresses may be prescribed, and
care must be exerted to avoid contact with
the cornea.
• Eye patches should be used cautiously
because of the potential for corneal abrasion
from the cornea coming in contact with the
patch.
35. ACHIEVING THERMOREGULATION
• Unconscious patients often develop
very high temperatures. Such
temperature elevations must be
controlled.
• Persistent hyperthermia with no
identified clinical source of infection
indicates brain stem damage and a
poor prognosis.
• Adjustment of the environment
depending on the patient’s condition to
promote a normal body temperature.
36. Continue
• If body temperature is elevated, a minimum
amount of bedding, a sheet or perhaps only a
small drape is used.
• The room may be cooled to 18.3°C
• If the patient is elderly and does not have an
elevated temperature, a warmer environment
is needed because of damage to the heat-
regulating center in the brain
• Frequent temperature monitoring is indicated
to assess the response to the therapy and to
prevent an excessive decrease in temperature
and shivering.
37. Strategies for reducing fever include:
• Removing all bedding over the
patient
• Administering repeated doses of
acetaminophen as prescribed
• Giving a cool sponge bath and
allowing an electric fan to blow over
the patient to increase surface
cooling
• Using a hypothermia blanket
38. PREVENTING URINARY RETENTION
• The bladder is palpated or scanned at
intervals to determine whether urinary
retention is present
• Indwelling urinary catheter attached to a
closed drainage system is inserted.
• A catheter may be inserted during the
acute phase of illness to monitor urinary
output.
• Observe the patient for fever and cloudy
urine.
39. Continue
• Inspect the area around the urethral orifice
for drainage.
• Although many unconscious patients
urinate spontaneously after catheter
removal, the bladder should be palpated
or scanned with a portable ultrasound
device periodically for urinary retention.
• An intermittent catheterization program
may be initiated to ensure complete
emptying of the bladder at intervals.
40. Continue
• If indicated an external catheter
(condom catheter) for the male patient
and absorbent pads for the female
patient can be used for the unconscious
patient who can urinate spontaneously
although involuntarily.
• As soon as consciousness is regained,
a bladder-training program is initiated.
• Frequently skin monitoring for irritation
and skin breakdown.
• Appropriate skin care is implemented to
prevent complication.
41. PROMOTING BOWEL FUNCTION
• Assess the abdomen for distention by
listening for bowel sounds and measuring the
girth of the abdomen with a tape measure.
• Commercial fecal collection bags for patients
with fecal incontinence.
• Monitors the number and consistency of
bowel movements
• Performs a rectal examination for signs of
fecal impaction.
• Stool softeners may be prescribed
• A glycerine suppository may be indicated to
facilitate bowel emptying.
• The patient may require an enema every
42. PROVIDING SENSORY STIMULATION
• keeping the usual day and night
patterns for activity and sleep.
• Touches and talks to the patient and
encourages family members and
friends to do so.
• Communication is extremely important
and includes touching the patient and
spending enough time with him or her.
• Avoid making any negative comments
about the patient’s status or prognosis
in the patient’s presence.
43. Continue
• Minimize the stimulation to the patient
by limiting background noises, having
only one person speak to the patient at
a time,
• Giving the patient a longer period of
time to respond, and allowing for
frequent rest or quiet times.
• When the patient has regained
consciousness, videotaped family or
social events may assist the patient in
recognizing family and friends and allow
him or her to experience missed events.
44. Continue
• Orients the patient to time and place at
least once every 8 hours.
• Sounds from the patient’s home and
workplace may be introduced using a
tape recorder.
• Family members can read to the patient
from a favorite book and may suggest
radio and television programs that the
patient previously enjoyed as a means
of enriching the environment and
providing familiar input.
45. MEETING FAMILIES’ NEEDS
• Reinforce and clarify information about
the patient’s condition.
• Permit the family to be involved in care.
• Listen to and encourage ventilation of
feelings and concerns while supporting
them in their decision-making process
about post hospitalization management
and placement.
• Families may benefit from participation
in support groups offered through the
hospital, rehabilitation facility, or
community organizations.
47. EXPECTED PATIENT OUTCOMES
• Maintains clear airway and demonstrates
appropriate breath sounds
• Experiences no injuries
• Attains/maintains adequate fluid status
• a. Has no clinical signs or symptoms of
dehydration
• b. Demonstrates normal range of serum
electrolytes
• c. Has no clinical signs or symptoms of over
hydration
• Attains/maintains healthy oral mucous
membranes
• Maintains normal skin integrity
48. Continue
• Has no corneal irritation
• Attains or maintains thermoregulation
• Has no urinary retention
• Has no diarrhea or fecal impaction
• Receives appropriate sensory
stimulation
• Family members cope with crisis
• a. Verbalize fears and concerns
• b. Participate in patient’s care and
provide sensory stimulation by talking
and touching
49. Continue
• Is free of complications
• a. Has arterial blood gas values within
normal range
• b. Displays no signs or symptoms of
pneumonia
• c. Exhibits intact skin over pressure
areas
• d. Does not develop deep vein
thrombosis