Altered LOC. Flashcards
Alert:
attends to 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.
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 mutter or moan as a verbal response.
Comatose:
no observable response to any external stimulation.
Persistent vegetative state:
after brain injury; no cognitive function; have sleep-wake cycles; no voluntary movement.
Locked-in syndrome:
motor pathway destroyed; cognitive fx but no motor; communicates by eye movement.
Structural causes of LOC:
trauma, vascular, infection, neoplasms.
Metabolic causes of LOC:
hypoxic encephalopathy, toxins, body temp extremes, seizures; HHNK, DKA, hypoglycemia.
Glasgow coma scale:
eye opening: spontaneous – 4, to speech – 3, to pain – 2 , none – 1.
verbal response: oriented – 5, confused – 4, inappropriate – 3, incomprehensible -2, none – 1.
motor response: obeys commands – 6, localizes to pain – 5, withdraws form pain – 4, flexion to pain -3, extension to pain – 2, none – 1.
Interventions for LOC:
ABC’s: support ventilation; head of bed up 30 degrees; avoid aspiration; turn to remove secretions; assess lung sounds; pulse ox; ABG’s; improve tissue perfusion: improve CO, hydrate, and turn q2 hours to improve venous return, TOM, TEDS; orient: sight, hearing, avoid neglecting; assess ability to chew; minimize confusing arrangement; clocks and calendars; pictures of family/friends; turn off lights at night; be patient and consistent; slow speech; body temp management: may need antipyretics or warming/cooling blankets; prevent injury: pad side rails if seizure risk; call light in reach; elimination needs; mobility: ROM, ambulation; skin care; nutrition; elimination needs; skin integrity; self-care.
Intracranial volume:
brain tissue - 80%, CSF - 10%, blood - 10%
Monroe-Kellie Doctrine:
an increase of volume of one intracranial component must be compensated by decrease in one or more of the other components so total volume remains fixed. Normal ICP ranges from 0-15 mmHg.
Causes of increased ICP:
head injury, CVA, inflammatory lesions, brain tumors, intracranial surgery, CO2.
If a patient becomes acutely unconscious, manage it as…
an actual or potential elevation in ICP.
Factors that increase brain matter:
cerebral edema, tumor, hemorrhage.
Factors that increase cerebral blood flow:
hypoxemia, hypercapnia, anesthetic agents, histamines, acidosis, and some antihypertensives.
Increase in CO2:
relaxes smooth muscle, dilates cerebral vessels, decreases vascular resistance, increasing cerebral blood flow.
Factors that increase CSF:
CSF, hydrocephalus, obstruction of CSF drainage pathways, lesions.
Causes of transient increase in ICP:
Valsalva, isometric muscle contractions, shivering, decerebration, coughing/sneezing, REM sleep, noxious stimuli.
Increased ICP is a ___.
medical emergency!
Immediate tx of increased ICP:
fluid restriction, osmotic and loop diuretics, corticosteroids, anti-seizure meds, stool softener.
Decrease ICP by:
HOB up.
With increased ICP, monitor:
draining of CSF, hypoventilation, fever, fluid and electrolytes.
Mild hyperventilation…
reduces PaCO2 = increased cerebral vasoconstriction = reduced cerebral blood flow = increased venous return = reduced ICP.
With increased ICP…
increased need for glucose.
Fluid should be…
restricted to reduce cerebral edema.
Care of patient with increased ICP:
avoid hypotension and hypoxia, HOB elevated at 30, avoid jugular venous outflow obstruction, prevent/avoid coughing/valsalva/hip flexion/high PEEP, prevent agitation, decrease stimuli, body positioning.
don’t cluster.
Early stage of increased ICP:
change in LOC (confusion, lethargy, restlessness), pupillary dysfunction, decreased visual acuity, motor weakness, headache.
Later stage of increased ICP:
decreased LOC, vomiting, hemiplegia/hemiparesis, posturing, vital sign changes (Cushing’s triad), papilledemia (long standing increase in ICP).
Headaches:
90% vascular or muscle contraction, 10% from underlying intracranial, systemic, or psychological disorder.
Four types of migraines:
classec, common, hemiplegic/opthalmoplegic, and basilar artery.
Classic:
may begin with aura; few hours to a few days.
S/S of classic migraine:
seeing stripes, spots, lines, scotomata, light and noise sensitivity.
Before a classic migraine:
mood changes, fatigue, difficulty thinking, depression, sleepiness, hunger, thirst.
Common:
lasts longer than classic, similar onset, light and noise sensitivity.
Hemiplegic/opthalmoplegic:
rare, severe unilateral pain, extraocular muscle palsy, ptosis, hemiplegia.
Basilar artery:
young females before periods, prodromal - vision loss, vertigo, ataxia, dysarthria, tinnitus, tingling of fingers and toes; severe occipital throbbing, vomiting.
Muscle contraction headache:
dull, persistent; tender spots on head and neck “hatband.”
Intracranial bleed headache:
neuro deficits, narcotics fail to relieve; bleed can be in subdural or subarachnoid.
Cluster headache:
early adult, more in males, episodes cluster together; throbbing, unilateral pain; infraorbital from head to neck; flushing, tearing, stuffy nose; severe form of head pain.
Cluster headache onset and tx:
at night, abrupt; tx: verapamil, lithium, NSAIDs; narcotic analgesic.
Tension headache:
no family hx; often in adolescents; dull, bilateral, neck-shoulder; no prodromal; can last hours to days; tx with ASA or tylenol.
Cerebral aneurysm:
Berry - most common type; occur at bifurcation in Circle of Willis; more adults than children, more females than males.
Causes of subarachnoid hemorrhage from aneurysm:
congenital defect of vessel wall, head trauma, hypertension, hold age, infection, atherosclerosis.
Symptoms of cerebral aneurysm:
sudden severe headache, NV, loss of consciousness, preceded by activity, nuchal rigidity, fever, restless - irritability - blurred vision - seizure.
