Acute Care Exam 3 // Altered Level of Consciousness

Aconnectic mutismthe pt makes no voluntary movement, unresponsive to environment but they look like they are awake. They will not talk to you and even if you do painful stimuli they will not respond.Minimally conscious statemay or may not open eyes, they have reproducible signs of awareness. They will respond the same way to the same stimuli.Brain deadno reversible causes known Irreversible caseation of totally brain function Unresponsive to stimuli No brainstem reflexes No respiratory effort with CO2 Flat EEG for a certain period of time2 EEG's 12 hours apartHow do you diagnose brain dead?Trauma - hit to the head, damage to the brain Vascular - clot or hemorrhage - stroke to the area of the brain Infection - can cause altered LOC Neoplasms - cancer - or even space occupying lesions like benign lesions. Putting pressure on the brain which causes problems (intercranial pressure)What are structural causes of altered level of conscious?Hypoxic encephalopathies Toxins Body temp extremes SeizuresMetabolic Causes of Altered level of conscious ?status epilepticusSeizure that goes on and on and doesnt stop medical team cannot even stop it. can lead to deathperiodic epilepsyIf a pt has status epilepticus from an injury or something, they may develop what within 2 years of that problem?15Patient spontaneously opens eyes when you walk into the room, his verbal response is oriented and he obeys commands. What is his glasgow coma scale?12Patient opens eyes to speech, he is confused and localizes to pain, what is his glasgow coma scale?9Patients eyes open only to pain and his speech is inappropriate and he withdraws from pain, what is his glasgow coma scale?4What is eye opening spontaneously?3What is eye opening to speech?2What is eye opening to pain?1What is no eye opening?5What is verbal response oriented?4What is verbal response confused?3What is verbal response inappropriate?2What is verbal response incomprehensible?1What is no verbal response?6What is motor response obeys commands?5What is motor response localizes to pain?4What is motor response withdraws from pain?3What is motor response flexion to pain?2What is motor response extension to pain1What is no motor response?13-15What is a mild glasgow score?9-12What is a moderate glasgow score?8 or belowWhat is a severe glasgow coma scale?Infection from pressure ulcers!!!!! turn q2h Take care of patients skin because they cannot move themselves police the areas they cannot feel and moveWhat is the most common path to death with brain injury patients after the acute phase within 20 years?Mental status Cranial nerve function Cerebral function Reflexes - motor and sensoryA good neuro assessment involves what?assess respiratory status vital signs reflexes neuro checks also: circulation respiration elimination fluid and electrolyteWhen you have a neuro problem/injury what things to you need to be assessing on an ongoing basis?This is an elimination problem because this can cause the blood pressure to go out of wack due to a full bladder and rectum MONITOR INTAKE AND OUTPUTWhat is automonic dysreflexia?alot will be on TPN - feeding tubesNutrition with neuro patients?Pneumonia aspiration respiratory failure impaired skin integrity pulmonary emboli DVT contractorsWhat are some complications to be looking at for neuro patients?Cerebral perfusion pressureMean arterial pressure subtracted intercranial pressure = what?70mmhg - 100mmhgWhat is a normal Cerebral perfusion pressure?70mmhg to prevent cerebral ischemiaWhat is the goal to keep Cerebral perfusion pressure above and why?81Patients MAP is 120 and intercranial pressure is 39 what is the cerebral perfusion pressure?50-150What do we want the systolic pressure to be?less than 40What do we want the intercranial pressure to be?they can experience irreversible brain damageThe patients systolic bp is below 50 what do we expect?If at any time the intercranial pressure = the mean arterial pressure, then circulation completely stops in the brain meaning high intercranial pressure or low blood pressure/mean arterial pressureIf the intercranial pressure is 40 and the MAP is 40 what happens?cerebral perfusion pressureChanges to intercranial pressure are closely linked to what?Cushing's response/syndromecerebral blood flow is decreased significantly so the vasomotor center triggers an increase in arterial pressure to overcome an increased intercranial pressure basically the brain tells the blood pressure to go up what is this called?very late neurological sign that is a cause for IMMEDIATE INTERVENTION!What does it mean when a patient has Cushing's response/syndrome?INTERVENTION!! Cushing's response/syndrome a neuro patient and their bp randomly goes up, something needs to be done!When taking your patients blood pressure at 0700 it was 112/74. At 0900 bp has risen without any cause to 174/102. What do you assume?Bradycardia - slow hr Hypertension - high bp Bradypnea - slow rrWhat are the signs of cushing's triad?Cushing's triadThe brain is attempting to regulate but its ineffective and the body is decompensating Hemmhorage might happen at this point due to the intercranial pressure is so highavoid - hypotension decreases CPP and Hypoxia decreases oxygenation to brain tissueWhat can hypotension and hypoxia do?HOB elevated 30 - decreases intercranial pressureHow should a neuro patient lay?Avoid jugular venous outflow obstruction - pressure to the neck Prevent/avoid coughing, Valsalva, hip flexion, high Pulmonary end expiratory pressure (which increases ICP) Prevent seizures Prevent and treat agitation Control fever - increased temp increases metabolic needsWhat are some other ways to prevent increased intercranial pressure/ care for?Assess - vital signs - call the doctorA patient has a sudden change in level of consciousness/mental change/ restlessness/ increased drowsiness. She is not acting right. What is the priority intervention?no - can cause hemmhorageShould you do lumbar punctures in people who have increased intercranial pressure?osmotic diuretics - mannitol: Prevents overload Barbiturates - phenobarbitol: for treatment of refractory ICPWhat are some medications we give to patients with Intercranial pressure?fluid restrictionPatients who have intercranial pressure should be on what kind of fluid precautions?avoid shivering - increases metabolism by 400% warm blankets but not too hotICP patients is cold, is this okay?Early increased ICP s/sDecreased level of consciousness Headache Pupillary changes (dilation & slow constriction, Ptosis) opposite side motor or sensory loss Widening pulse pressurelate increased ICP s/sMore decrease LOC Changes in VS (SBP up, DBP fall, Widened PP, slow pulse) Respiratory changes (usually decreases) Fever: unknown origin Vomiting Posturing Headachescerebral aneurysmweakness in arterial wall that allows it to balloon out - dilation in the walls of the artery and where its weakBerry - most common type in the brain - look like a round berry and can be seen on angiogramWhat is the most common type of cerebral aneurysm?Occur @ bifurcations in Circle of WillisWhere do cerebral aneurysm occur?50% die immediatelyWhat is the result of a Subarachnoid hemorrhage from aneurysm?- often cause is unknown Tend to run in families congenital defect of vessel wall head trauma hypertension old age infection atheroslerosisWhat are the causes of cerebral aneurysms?Ruptured Berry Aneurysm in Circle of Willis Most common arteries involved are internal carotid - Anterior cerebral, internal carotid, anterior communicating, middle cerebral, postural cerebral - really any of these arteries around the circle of willisWhat causes the actual cerebral aneurysm to occur?Always Subarachnoid hemorrhage and cerebral infarction Caused by cerebral-vasospasm --> usually will rupture and 40% die Re-bleed with in 7 days to 6 months is very high Person will have surgery for it usually Wait about a week after bleed to do surgery bc of collateral circulation will get betterWhat are the complications that lead to cerebral aneurysm?• Sudden severe HA - terrible HA • N/V • Loss of consciousness • Preceded by activity • Nuchal rigidity - neck stiffness - due to cerebrospinal fluid • Fever • Restless--> irritability--> blurred vision--> seizureSymptoms of Cerebral AneurysmChanges in LOC (deterioration) unequal pupils (1 enlarged) worsening hemiplegia new or worse headache notify MD if systolic BP increases Rebleeding, cerebral vasospasm, hydrocephalusSymptoms to watch: Cerebral AneurysmO2 Ventilation Surgical intervention If delayed: BR, quiet dark room Phenobarbital No stimulants Calcium Channel Bl. Codeine/analgesia prn Antihypertensives ****Corticosteroids - to decrease swellingWhat is the treatment for Cerebral Aneurysm?