nursing care of patients with altered level of consciousness Flashcards
Altered level of consciousness
condition when a person is not oriented, does not follow command or needs persistent stimuli to be awake
causes of ALC
neurologic - head injury (blunt, open etc.)
toxins- drug OD, any toxics
metabolic - hepatic encephalopahty
effects of ALC
disruption- cells of nervous system; neurotransmitters (acetylcholine and dopamine not functioning properly), brain anatomy (injury)
sign and symptom of ALC
- subtle behavior changes like restless, anxiety (these are earliest signs)
- pupil changes (PERLA)
What assessments exams/scales do we use to determine changes in ALC
Mini-mental status examination (MMSE), glasgow coma scale
MMSE
30 points available
score of below 20-23
=> cognitive impairment
- give simple objects
ex: pencil, apple
diagnostic and lab tests for ALC
CT head, MRI, EEG, PET, blood glucose, ammonia (hepatic encephalopathy/hepatic issues) serum osmolality, Na (esp hyponatremia) , BUN &creatinine, ketones, alcohol level, ABG, drugs both illicit and legal
nursing interventions ALC
maintain patient airway, patient safety, fluids and nutritional needs, oral care
postion for ALC
Head of the bed at 30degrees angle - lateral or semi-prone position ----REASON: prevent aspiration -----never put unconscious patient flat should be a suction machine available.
patient safety for ALC
confused = fall risk
- may pull out devices, may pull up side rails, uses resources like blankets, 4 side rails - need order- for acute its okay - just get order after
fluids and nutritional needs ALC
NGT, IV
oral care ALC
dry lips, dry tongue
nursing interventions for ALC
skin and joint integrity - proper positioning turn pt Q 2 hrs , corneal integrity - cornea may be dry use artificial tears, bowel functioning- prevent constipation, family needs
