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Neurologic Dysfunction
Altered Level of Consciousness (LOC)
Decerebrate
Nursing Process—Diagnosis of the Patient With
Altered Level of Consciousness
Pneumonia
Aspiration
Pressure ulcer
Contractures
Nursing Process—Planning the Care of the
Patient With Altered LOC
Goals include:
Maintenance of clear airway
Protection from injury
Attainment of fluid volume balance
Maintenance of skin integrity
Absence of corneal irritation
Effective thermoregulation
Accurate perception of environmental stimuli
Maintenance of intact family or support system
Absence of complications
Interventions
Assess skin frequently, especially areas with high potential for breakdown
Turn patient frequently; use turning schedule
Carefully position patient in correct body alignment
Perform passive range of motion
Use splints, foam boots, trochanter rolls, and specialty beds as needed
Clean eyes with cotton balls moistened with saline
Use artificial tears as prescribed
Talk to and touch the patient and encourage the family to talk to and touch
the patient
Maintain normal day–night pattern of activity
Orient the patient frequently
A patient aroused from coma may experience a period of agitation;
minimize stimulation at this time
Initiate programs for sensory stimulation
Allow family to ventilate and provide support
Reinforce and provide consistent information to family
Projectile vomiting
Manifestations of Increased ICP—Late
(cont.)
Diabetes insipidus
SIADH
Infection
Patient With Increased
Intracranial Pressure
Fluid balance
Absence of infection
Interventions
Increased ICP
Infection
Seizures
Nursing Process—Planning the Care of the
Patient Undergoing Intracranial Surgery
Absence of complications
Maintaining Cerebral Perfusion
Regulate temperature
Cover patient appropriately
Treat high temperature elevations vigorously; apply ice bags, use
hypothermia blanket, and administer prescribed acetaminophen
Improve gas exchange
Turn and reposition the patient every 2 hours
Encourage deep breathing and incentive spirometry
Suction or encourage coughing cautiously as needed (suctioning and
coughing increase ICP)
Humidify oxygen to help loosen secretions
Interventions (cont.)
Sensory deprivation
Periorbital may impair vision, so announce your presence to avoid
startling the patient; cool compresses over eyes and HOB
elevation may be used to reduce edema if not contraindicated
Enhance self-image
Encourage verbalization
Encourage social interaction and social support
Pay attention to grooming
Cover head with turban and later with a wig
Interventions (cont.)
Cerebrovascular disease
Hypoxemia
Fever (childhood)
Head injury
Hypertension
Central nervous system infections
Metabolic and toxic conditions
Brain tumor
Drug and alcohol withdrawal
Allergies
Tonic-clonic contractions
Plan of Care for a Patient
Experiencing a Seizure