Chapter 16: Mentation and Sensory Motor Complications of Acute Illness Flashcards
Describe the National Institutes of Health Stroke Scale (NIHSS)
Quantifies Stroke; does not guide treatment. Predicts Outcome, DOES NOT GUIDE TX. Need to be trained and certified to perform. Black and White—score what you see, not what you think the patient can or can’t do. Gold standard in stroke scales. Reliable and valid tool. Score Ranges (0 to 42) 1-4 Minor 5-15 moderate 15-20 Moderately Severe >20 Severe Stroke
What is the difference between delirium and dementia?
Delirium: acute, doesn’t last long (maybe hours to days), symptoms may change, worse at night, in the dark and on awakening, rapid mood swings, alertness changes going from lethargic or hypervigilant, attention is impaired, orientation fluctuates in severity.
Dementia: is chronic, it lasts a long time and symptoms are progressive, it lasts months-years, person may be depressed or disinterested, generally alert and attentive, orientation may be impaired.
Describe hyperactive delirium.
ICU psychosis. Less common than hypoactive delirium and is associated with a better overall prognosis. Agitation and restlessness, picking at lines and tubes.
Describe hypoactive delirium. Mixed delirium?
Lethargy (rather than agitation), withdrawal, flat affect, apathy, and decreased responsiveness, usually referred to as encephalopathy. Most common form & worse for the patient in the long term, and remains unrecognized in 66–84% of hospitalized patients. ASSESS for hypoactive delirium which has a worse prognosis.
Features of both hyperactive and hypoactive is called mixed delirium.
Describe septic encephalopathy.
Results from a non-CNS infection which leads to sepsis & occurs in 50–70% of ICU patients. It is an early sign of septicemia in the elderly population. Sepsis can lead to a major infection-induced syndrome characteristic by failure of vital organs, such as lung, brain, liver, and kidney.
What are some causes of delirium?
Preexisting cognitive impairment (e.g. dementia), Advanced Age, Acute Systemic Illness, (HTN, smoking, alcoholism, hypoxia, metabolic disturbances, electrolyte imbalances, acute infections, seizures, dehydration, fever, head trauma, sensory deficits, immobilization, poly-pharmacy), Bennzodiazepines, Sleep deprivation or loss of circadian rhythm (is another potentially modifiable risk factor for the development of delirium) due to excessive noise and lighting, patient care activities, metabolic consequences of critical illness, mechanical ventilation, and sedative and analgesic medications.
Describe the nursing management of a patient with delirium.
Provide frequent orientation: Clock, white boards, calendar, window with a clear view. Ensure hearing aids and/or glasses always on to prevent sensory isolation. Maintain nutrition & hydration. Manage sleep. Keep Room well lit during the day. Dark, quiet room at night. Provide periods of undisturbed sleep. Keep active during day. Encourage family/friend visitation. Determine family’s capacity to provide a calming/orienting environment. Treat pain adequately. ICU considerations for ventilated patients include Propofol drips (Anesthetic Agent) and Dexmedetomidine (Precedex) which does not cause respiratory depression. Sedation Vacations. Use Richmond Agitation Sedation Scale (RASS) scale to assess for adequate sedation.
What medications will the doctor give a patient with delirium?
Risperidone, olozapine, quetiapine. Watch for heart abnormalities such as QT prolongation, prolonged QT interval, and torsades de pointes. Haloperidol is awesome.
What is a coma?
Bilateral, diffuse cerebral hemispheric dysfunction. Most severe and critical state as it implies extensive brain injury.
Coma is often reversible if cause is treated quickly.
Longer patient comatose, the more neuro deficits upon emergence.
What can cause a coma?
Cardiac arrest, intracerebral hemorrhage, infection, toxins, metabolic disorders such as hypoxia, hypoglycemia, sedative overdose, barbiturate coma (medically caused to decrease metabolism).
Describe PVS.
Patient continues to maintain the arousal component of consciousness but not awareness. Characterized by periods of wakefulness in which the eyes are open and may appear to visually wander around the immediate environment. Patient retains autonomic function such as swallowing, coughing, and yawning, and some movement of the head and limbs; however, there are no meaningful responses to the internal or external environments. Prognosis for recovery from PVS that persists for more than several months is extremely poor. Families of patients with PVS may misinterpret the wandering eye movements and autonomic activities as being meaningful, giving false hope of eventual recovery. Healthcare team to provide information about PVS and the cause of the patient’s “awake” behaviors, as well as to provide psychosocial support to family members.
Describe brain death.
Irreversible loss of all brain and brain- stem function. Severe brain injury (usually traumatic) resulting in global cerebral hypo-perfusion. Diagnosis of brain death requires that the patient meet established brain death criteria that include tests to demonstrate the loss of all cerebral and brain- stem function. Assess with glasgow coma scale.
Describe the nursing management of a person with a coma.
Major goal in early management is to prevent further deterioration of the neurologic system. Coma is often reversible when treated quickly. Identify and correct the underlying cause. The nurse meets the patient’s supportive needs such as airway, nutrition and elimination, and hygiene. Patient is often in a critical care setting on continuous cardiac monitoring. Mechanical ventilation may be required to protect the airway, promote oxygenation, and prevent hypoventilation. Intravenous access is needed to provide fluid and medications, and may also be used for hemodynamic monitoring. An enteral feeding tube may be inserted to provide nutrition support. Communication with patient family is very important.
Describe critical illness polyneuropathy.
Mainly affects the lower limbs. Happens after septic encephalopathy and is followed by difficulty weaning from the ventilator. Symptoms include: reduced or absent movement of limb when pain is applied but may demonstrate pain, distal loss of pain, temp, and vibration sensory abilities, DTRs & autonomic function intact. Dx: electrodiagnostic testing. Tx: prevent
Describe critical illness myopathy.
Diffuse weakness, loss of DTRs, and slightly elevated creatinine kinase levels. Dx: electrodiagnostic testing. May have status asthmaticus. Tx: non-specific, usually recover in a few months. Management: observation of o2 & ventilator, pulmonary hygiene, tracheal intubation, supplemental o2, mechanical ventilation, and PEEP.
