Altered Intracranial Function

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Altered Intracranial Function
2011-02-09 16:26:44
altered function seizure

Altered Intracranial Function
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  1. Consciousness
    awareness of self and environment, responds appropriately to stimuli
  2. Alertness and Cognition Needed:
    1. Alertness depends on reticular activation system (RAS) stimulation in thalmus and upper brainstem

    2. Cognition is controlled by cerebral hemipsheres - thoughts, memory, perception, problem-solving, emotion

    3. Nurse should assess patient's behavior and response to stimuli
  3. Altered Level of Consciousness
    • - Changes in alterness and/or cognition, solving complex problems
    • *Neurologic: head injury, stroke
    • *Toxicologic: OD, ETOH
    • *Metabolic disorders: hypoxia, hypoglycemia

    • - Localized & systemic disorders also affect LOC
    • *Trauma, ICP, CVA, hematoma, infection, demyelinating disorders

    - Any condition that affects delivery of blood, O2, glucose to brain

    - Seizure activity affects LOC
  4. Assessment of Unconscious Patient
    • - Pattern of respiration (irregularities)
    • - Eye signs
    • - Abnormal posturing
    • - Reflexes
    • - Level of Responsiveness
    • - Assymetry
  5. Assessement
    VS & Breathing Patterns
    Changes - airway --> ETT
  6. Assessment
    Pupillary and Oculomotor Responses
    • Localized --> ipsilateral; systemic-->pupils = affected
    • Metabolic --> small, =reactive
    • Fixed, unresponsive to light -->dilated
    • Spontaneous/reflexive eye mvmt altered
    • Doll's eyes present/absent - passive head
  7. Assessment
    Motor responses norm to flaccid
    • Strong vs weak, note ubable to lift
    • Withdrawal, fimiacing - flexor response
    • Decorticate mvmt - flexion upper
    • Decerebrate posturing - adduction and rigid ext of upper and lower
    • Flaccidity follows - no response to stimulation
  8. Assessment
    Restlessness, confusion, forgetfulness, disorientation, agitation, poor problem-solving, any change

    As impairment progresses, more stimuli to elicit a response

    Alert --> difficult to arouse, agitated, confused, small pupils --> disorientated to time, place, person

    Continuous stimulation --> no response, pupils dilated
  9. Assessment
    Persistent Vegatative State
    Complete unawareness of self and enviornment, sleep/wake, chews, swallows, coughs - use Glascow Coma Scale
  10. Assessment
    Brain Death
    Permanent loss of fuction; unresponsive, absent motor and reflexes (no elecetro function for 6-24hrs)
  11. Nursing Diagnoses for Altered Function
    • Inefffective Airway Clearance
    • Risk for Aspiration
    • Risk for Impaired Skin Integrity
    • Risk for Injury
    • Impaired Physical Mobiliity
    • Risk for Altered Nutrition: less than body requirements
    • Risk for Infection
    • Altered Family Coping
  12. Nursing Interventions for Altered Function
    • Maintain airway
    • Protect the patient
    • Maintain fluid balance
    • Manage nutritional needs
    • Provide mouth care
    • Maintain skin and joint integrity
    • Preserve corneal integrity
    • Maintain thermoregulation
    • Prevent urinary retention
    • Promote bowel function
    • Provide sensory stimulation
    • Medication management
    • Meet family needs
  13. Labs and Diagnostics
    Glucose, electrolyes, osmolarity, BUN, creatinine, LFT's, ABG's, toxivology screen, CBC, LP

    CT, MRI, EEG, Brain scan, cerebral angiography, transcranial doppler