Altered LOC. Flashcards

1
Q

Alert:

A

attends to environment, responds appropriately to commands and questions with minimal stimulation.

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2
Q

Confused:

A

disoriented to surroundings, may have impaired judgment, may need cues to respond to commands.

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3
Q

Lethargic:

A

drowsy, needs gentle verbal or touch stimulation to initiate response.

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4
Q

Obtunded:

A

responds slowly to external stimulation, needs repeated stimulation to maintain attention and response to the environment.

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5
Q

Stuporous:

A

responds only minimally with vigorous stimulation, may only mutter or moan as a verbal response.

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6
Q

Comatose:

A

no observable response to any external stimulation.

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7
Q

Persistent vegetative state:

A

after brain injury; no cognitive function; have sleep-wake cycles; no voluntary movement.

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8
Q

Locked-in syndrome:

A

motor pathway destroyed; cognitive fx but no motor; communicates by eye movement.

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9
Q

Structural causes of LOC:

A

trauma, vascular, infection, neoplasms.

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10
Q

Metabolic causes of LOC:

A

hypoxic encephalopathy, toxins, body temp extremes, seizures; HHNK, DKA, hypoglycemia.

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11
Q

Glasgow coma scale:

A

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.

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12
Q

Interventions for LOC:

A

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.

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13
Q

Intracranial volume:

A

brain tissue - 80%, CSF - 10%, blood - 10%

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14
Q

Monroe-Kellie Doctrine:

A

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.

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15
Q

Causes of increased ICP:

A

head injury, CVA, inflammatory lesions, brain tumors, intracranial surgery, CO2.

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16
Q

If a patient becomes acutely unconscious, manage it as…

A

an actual or potential elevation in ICP.

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17
Q

Factors that increase brain matter:

A

cerebral edema, tumor, hemorrhage.

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18
Q

Factors that increase cerebral blood flow:

A

hypoxemia, hypercapnia, anesthetic agents, histamines, acidosis, and some antihypertensives.

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19
Q

Increase in CO2:

A

relaxes smooth muscle, dilates cerebral vessels, decreases vascular resistance, increasing cerebral blood flow.

20
Q

Factors that increase CSF:

A

CSF, hydrocephalus, obstruction of CSF drainage pathways, lesions.

21
Q

Causes of transient increase in ICP:

A

Valsalva, isometric muscle contractions, shivering, decerebration, coughing/sneezing, REM sleep, noxious stimuli.

22
Q

Increased ICP is a ___.

A

medical emergency!

23
Q

Immediate tx of increased ICP:

A

fluid restriction, osmotic and loop diuretics, corticosteroids, anti-seizure meds, stool softener.

24
Q

Decrease ICP by:

25
With increased ICP, monitor:
draining of CSF, hypoventilation, fever, fluid and electrolytes.
26
Mild hyperventilation...
reduces PaCO2 = increased cerebral vasoconstriction = reduced cerebral blood flow = increased venous return = reduced ICP.
27
With increased ICP...
increased need for glucose.
28
Fluid should be...
restricted to reduce cerebral edema.
29
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.
30
Early stage of increased ICP:
change in LOC (confusion, lethargy, restlessness), pupillary dysfunction, decreased visual acuity, motor weakness, headache.
31
Later stage of increased ICP:
decreased LOC, vomiting, hemiplegia/hemiparesis, posturing, vital sign changes (Cushing's triad), papilledemia (long standing increase in ICP).
32
Headaches:
90% vascular or muscle contraction, 10% from underlying intracranial, systemic, or psychological disorder.
33
Four types of migraines:
classec, common, hemiplegic/opthalmoplegic, and basilar artery.
34
Classic:
may begin with aura; few hours to a few days.
35
S/S of classic migraine:
seeing stripes, spots, lines, scotomata, light and noise sensitivity.
36
Before a classic migraine:
mood changes, fatigue, difficulty thinking, depression, sleepiness, hunger, thirst.
37
Common:
lasts longer than classic, similar onset, light and noise sensitivity.
38
Hemiplegic/opthalmoplegic:
rare, severe unilateral pain, extraocular muscle palsy, ptosis, hemiplegia.
39
Basilar artery:
young females before periods, prodromal - vision loss, vertigo, ataxia, dysarthria, tinnitus, tingling of fingers and toes; severe occipital throbbing, vomiting.
40
Muscle contraction headache:
dull, persistent; tender spots on head and neck "hatband."
41
Intracranial bleed headache:
neuro deficits, narcotics fail to relieve; bleed can be in subdural or subarachnoid.
42
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.
43
Cluster headache onset and tx:
at night, abrupt; tx: verapamil, lithium, NSAIDs; narcotic analgesic.
44
Tension headache:
no family hx; often in adolescents; dull, bilateral, neck-shoulder; no prodromal; can last hours to days; tx with ASA or tylenol.
45
Cerebral aneurysm:
Berry - most common type; occur at bifurcation in Circle of Willis; more adults than children, more females than males.
46
Causes of subarachnoid hemorrhage from aneurysm:
congenital defect of vessel wall, head trauma, hypertension, hold age, infection, atherosclerosis.
47
Symptoms of cerebral aneurysm:
sudden severe headache, NV, loss of consciousness, preceded by activity, nuchal rigidity, fever, restless - irritability - blurred vision - seizure.