LOC + SEIZURES

Question 1

What 3 clinical manifestations are present for Nursing Dx = Altered level of consciousness?

Answer 1

Not Oriented,
Does not follow commands,
needs persistent stimuli to achieve a state of alertness

Question 2

What clinical state of altered level of consciousness includes NO purposeful responses to internal/external stimuli AND nonpurposeful responses to PAINFUL stimuli and BRAINSTEM reflexes?

Answer 2

Coma = does not open eyes to voice or command, does not respond verbally, or move when requested to do so.

Question 3

What LOC state = unresponsive to environment and NO voluntary movement

Answer 3

Akinetic Mutism

Question 4

What 3 clinical manifestations = PERSISTENT VEGETATIVE STATE?

Answer 4

• Unresponsive
• Resumes sleep-wake cycle after coma
• devoid of cognitive/affective mental function

Question 5

What is 1 hallmark of MINIMALLY CONSCIOUS STATE for LOC?

Answer 5

Pt has inconsistent but reproducible signs of awareness.

Question 6

What LOC results from a lesion on the pons and manifests as paralysis and inability to speak?

Answer 6

Locked In Syndrome = vertical eye movement and lid elevation indicates responsiveness.

Question 7

Name 1 common patho cause of altered LOC?

Answer 7

Neuro injury r/t cellular edema

Question 8

What are 3 acute assessment findings for altererd LOC?

Answer 8

• Restlessness
• Increased anxiety
• No Pupil response to light

Abnormal pupil and motor response = NEURO DISEASE

Question 9

The cerebellar functions are what (2)?

Answer 9

Balance and Coordination

Question 10

What is the priority of treatment for the pt with altered LOC?

Answer 10

RESPIRATORY = Obtain and maintain patent airway.

Question 11

How to maintain airway patency for LOC pt?

Answer 11

MECHANICAL VENTALIATION

Question 12

Name 2 Nursing actions to manage altered LOC pt?

Answer 12

• Feeding Tube = for nutrition

- IV = for fluids and medications

Question 13

How to assess for LOC/What 3 Things are you assessing the pt for?

Answer 13

1) Verbal Response = orientation
2) Alertness = ability to open eyes/pupil response
3) Motor Response = purposeful spontaneous movement
*abnormal motor response to stimuli
= decorticate (plantar flex in feet, internal rotation of lower extremities, flexion of upper extremities)
=decerebrate (extension and outward rotation of upper extremities, plantar extension in feet)