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Care of the Patient with Altered Conscious Level

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James Garvey

on 7 April 2014

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Transcript of Care of the Patient with Altered Conscious Level

Care of the Patient with
altered conscious level

KNOWLEDGE & SKILLS FOR NURSING
Part II
OUTCOMES:
Understands process of the use of scoring tools
Identifies equipment required and the normal paranmeters for neurological function
Correctly documents the assessment
Identifies factors which may affect neurological function and care require to manage patients with altered conscious level.
A& P Review
What is the Function of the brain?
What does it require in order to function?
Oxygen
Blood
Calcium
Glucose
The brain controls the functioning of the body via electrical impulses
The functional units of the brain are neurones and glia cells
There are structures in the brain that control body temperature, heart rate, respiration and hormonal control.
States of Consciousness:

1. Fully Conscious
2. Drowsy / Lethargic
3. Comatosed
Reasons for Altered Conscious Level
Hypoxia - low saturations
Hypotension - light headed - loss of consciousness
Metabolic Disorders - Hypoglycaemia
Intoxication / drugs - alcohol, opiates
Cerebral lesion, infection, vascualr accident - haemorrhage, meningitis
Epilepsy
Concussion
Patient History

Mr. Taylor 25 has been admitted to the ward with a history of a head injury following a night out with friends.
He has consumed a large volume of alcohol and some cocaine. He is drowsy and unco-operative.
Has vomitted x 1
c/o severe headache, was aggressive and unco-operative
Signs & Symptoms

Why is he drowsy?
Why is his airway at risk?
Why does his alcohol and drug intoxication complicate his management?
Assessing Neurological Function

ABC
AVPU
GCS
Glasgow Coma Scale (GCS)
GCS is used to:

Establish a baseline
Determine if patient has a neurological problem
Detect life threatening situations
Determine changes in neurological condition over a period of time
National Standard
15 = Fully alert
6 = Comatosed
GCS evaluates:
eye opening
verbalisation
movement
Painful Stimuli

Used only if no response to firm, clear commands:

Supra-orbital push
Trapezius pinch

Do NOT apply pressure to the nail beds or sternum
Flexion (Decorticate Response)
abnormal posturing indicating severe brain injury
Upper arms held tightly to the sides with elbows, wrists and fingers flexed.
The legs are extended and internally rotated.
The feet are planted and flexed.
Extension (Decerebrate Response)

Jaws clenched and neck extended
Arms are adducted and extended at elbows
Wrist and fingers are flexed
Legs extended, feet plantar flexed
Pupils - occulomotor nerve

Pupils should be black, round and react briskly to light.
Pupil response to light is extremely important
Normal - size 3-6mm, react briskly and are equal in size
In certain instances pupils may vary in size.
Differing pupil size is inherited and there is no underlying disorder
It can however also be due to trauma, tumours, disease or infection
Record the size of the pupil when eye is first opened, NOT after you have checked for a reaction

Check for a consensual response

Check for any deviation of the eyes
Pupil Response

Equal Pupils:
Small and Reactive - enchephalopathy
Pinpoint & Fixed - brainstem lesion, opioids
Dilated and Reactive - lesions, drugs
Dilated and Fixed - hypoxia, anticholinergics
Unequal:
Unilateral dilated pupil - ? pressure due to haemorrhage - compression - may need CT scan and urgent surgical decompression
Vital Signs

Pulse
Blood Pressure
Respirations
O2 Saturations
Temperature
Mr. Taylor has been on the ward for 4hrs not showing signs of improvement.
He is less alert, eyes opening to pain and is becoming increasingly confused and agitated using inappropriate words.
He is localisng to pain.
What is his GCS?

You inform the doctor who arranges a scan ? sub-dural haematoma.
What signs and symptoms would you expect to find in a patient with this problem?
A history of recent head injury
Loss of consciousness
Irritability
Seizures
Pain
Numbness
Headaches
Dizziness
Disorientation
Amnesia
Weakness / lethargy
Nausea / Vomiting
Dysphagia / slurred speech
Ataxia - lack of coordination of muscles
Visual disturbances
Recording Observations
Nursing Care
Summary

Primary role of the nurse in managing patients with reduced levels of consciousness is to keep them safe

Klein-Levin Syndrome
Fatal Familial Insomnia
Nursing management will depend on the cause of the altered conscious level
Monitor and report any changes to the patient's condition and document all aspects of care.
Provide Basic Care and assistance with all ADLs
Support relatives as they can often be very distressed
Patients often require a lot of rehabilitation and support following injuries / illness which cause altered levels of consciousness
The End

Any Questions?

The reticular activating system (RAS) is an area of the brain responsible for regulating arousal and sleep-wake transitions
ALERT
VOICE
PAIN
UNRESPONSIVE
Observations and monitoring
Assistance with all ADLS
Prevention of complications
Pain management
Maintain nutrition and hydration
Supporting Relatives
Ongoing support and rehabilitation following recovery including psychological care
Administration of prescribed medicines
Note any changes in alertness
limb movement - push and pull
physiotherapy referral
late signs: Cushings Reflex / Cheyne Stokes
Full transcript