This document discusses the nursing management of clients with neurologic dysfunction including altered level of consciousness, increased intracranial pressure, seizure disorders, and headaches. Key priorities include maintaining a patent airway, preventing injury, monitoring for complications, and providing education to patients and families. Nursing assessments, interventions, and goals target reducing symptoms and promoting optimal functioning and home care.

1. Managing clients with Neurologic Dysfunction Ma. Tosca Cybil A. Torres, RN, MAN

2. Outline Altered LOC

3. Increase ICP

4. Seizure disorders

5. Headache Altered Level of Consciousness client is not oriented, does not follow commands, or needs persistent stimuli to achieve a state of alertness.

6. 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 movementPersistent 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.

7. The level of responsiveness and consciousness is the MOST important indicator of the patient’s condition.

8. Causes of Altered LOCNeurologic

9. Toxicologic

10. Metabolic AssessmentIncludes:

11. Mental status

12. Cranial nerve function

13. Cerebellar function

14. Reflex, motor, and sensory function

15. Glasgow Coma Scale

16. Alertness

17. Motor response ComplicationsRespiratory failure

18. Pneumonia

19. Pressure ulcers

20. Aspiration

21. DVT

22. ContracturesMedical MgtThe first PRIORITY of tx for a client with altered LOC is to obtain and maintain a PATENT AIRWAY

23. Possible nursing diagnoses Ineffective airway clearance

24. Risk for injury

25. Deficient fluid volume

26. Risk for impaired skin integrity

27. Impaired tissue integrity of cornea

28. Ineffective thermoregulation

29. Bowel incontinence

30. Impaired urinary elimination

31. Disturbed sensory perception

32. Interrupted family processesThe 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.

33. If the client begins to emerge from unconsciousness, every measure that is available and appropriate in calming and quieting the client should be used.

34. Nursing Interventions Maintaining the airway

35. Protecting the client

36. Managing fluid balance and managing nutritional needs

37. Providing mouth care

38. Maintaining skin and joint integrity

39. Preserving corneal integrity

40. Maintaining body temperature

41. Prevent urinary retention

42. Promoting bowel function

43. Providing sensory stimulation

44. Managing the family’s needs