CHRIST JOHN S.

PAJARILLAGA
BSN IV – BLOCK 13

1. Describe several nursing interventions for maintaining the airway for a patient with an altered
level of consciousness.

Maintaining a patent airway need the highest priority in a patient with altered level
of consciousness. This is achieved through proper positioning of the client that is through
the elevation of the head of the bed to 30⁰ (semi-fowler’s) to prevent aspiration. Due to
lack of pharyngeal reflex and the patient can’t swallow his secretions which may lead to
obstruction. Other proper positions include lateral or semi-prone for it helps to the
drainage of secretion and prevention of aspiration.

Oral hygiene and suctioning are also important means in maintaining a patent
airway, but before suctioning, the patient should be hyperventilate to prevent hypoxia. In
severe cases intubation and mechanical ventilation maybe indicated.

2. Discuss 6 out of 12 major goals for a patient with altered level of consciousness.

a. Protection from injury

One of the major goals for patient with altered level of consciousness is protecting
the patient from injury; this is achieved to the padding of the side rails of the bed and
securing that the patient is at safe environment. Protection of the client is extended
to different factors that could cause harm to the client such as chemical irritants,
tube and draining, thigh dressing etc. Providing privacy is also vital for it ensure the
dignity of the client. Talking to the patient is also helpful for his development for in
some cases the patient who is in mild coma may able to hear what the nurses is
saying (so having a positive outlook is important).

b. Maintain fluid balance and managing nutritional status

Fluids and proper nutrition is vital in daily living of a healthy man as well as to the
patient with altered level of consciousness. Proper hydration could be accomplished
through the administration of IV fluid (it should be slowly administered to prevent
increase intracranial pressure). The amount of fluid may be limited to prevent
cerebral edema. In case that the patient may not recover easily NGT or NET feeding
may be indicated.

c. Maintenance of normal skin integrity.

Due to immobility a regular schedule of turning the patient is necessary to avoid
ulcer which may lead to breakdown and necrosis. Furthermore turning the patient
every 2 hours could prevent other complications such as orthostatic pneumonia.
Passive range of motion is important as well as maintaining the normal anatomy of
the body. This is achieved to prevent foot drop with the use of foot board and a
trochanter roll is used to support the hips the legs in proper alignment. These
measures are necessary especially during the recovery of the patient to maintain (to
assume) normal body functions.
 d. Absence of corneal irritation
In some patients they have their eyes open which may lead to lack or absence of
corneal reflex or dryness. To prevent this, proper cleaning of the eyes is necessary
this is achieved through the use of moistened cotton balls. Artificial tears may also be
used (if it is prescribed) to prevent dryness.

e. Promoting the bowel function

Proper assessment of the abdomen must be done to the patient with altered level
of consciousness. Diarrhea may occur due to infection or to side effects of antibiotics
and hyperosmolar fluid, in this case fecal collection bag should be available. Due to
immobility and lack of fiber intake the patient may experience constipation, in this
case laxatives or stool softeners must be administered. Glycerin suppository or
enema may also be indicated for bowel emptying.

f. Maintenance of intact family or support system

At some cases the family members of the patient may experience crisis and
knowledge deficit and because of this the nurse should be available and willing to
listen to their problems, feeling and concerns furthermore the nurse must help the
family with proper coping mechanisms and explain the condition of the client in a
manner that it could be easily understand by the family members. Family
involvement to care is also important.

3. Describe Cushing’s Reflex, a phenomenon seen when cerebral blood flow decreases
significantly.

Cushing’s reflex also known as Cushing’s response occurs when there is a significant
decrease in cerebral blood flow which may lead to ischemia. When ischemia occurs there
would be a compensatory mechanism that would occur, there would be an increase in
the arterial pressure to overcome an increase in intracranial pressure. There would be a
sympathetic response that would increase the systolic blood pressure while the diastolic
pressure remains normal due to this condition there would be a widening in the pulse
pressure and the reflexes slowing of the heart rate. Cushing’s reflex is a late sign
requiring immediate interventions.

4. Explain two trends in neurological monitoring: microdialysis and cerebral oxygenation

monitoring. 

Microdialysis is a method used to measure the substance that reflects to metabolic

functions of the brain. According to some researchers these substances may help for the
proper management of the patient. It is done by placing the cortical probe near the
injured area and then measuring of substances that reflects metabolic function of the
brain (such as glutamate and glucose) is done.

Another trend that is used today is monitoring the cerebral oxygenation through
monitoring the oxygen saturation in the jugular venous bulb or via catheter of the brain.
Cerebral oxygenation is thought to be important because changes in cerebral perfusion
may reflect an increase in ICP.
5. Distinguish between the early and late signs of ICP that a nurse would be responsible for
assessing.

EARLY SIGNS LATE SIGNS

 Change in change in level of  Change in vital signs
consciousness (Cushing’s Triad)
 Restless to confusion  Hypertension
 Irritability and  Bradypnea
agitation  Bradycardia
 Lethargy  Hyperthermia
 Stupor to coma

Early signs of increase intracranial pressure are caused by swelling from hemorrhage
or edema, an expanding intracranial lesion or a combination of both, where restlessness
is an early sign of cerebral hypoxia. When there would be a continuous increase in ICP
there would be a serious impairment of the brain circulation that needs immediate
interventions.
The late signs would be the change vital signs this is due to the impairment of
functions of the pons, brain stem and mid brain that has been damaged through
herniation or if there would be no immediate intervention to this situation.

6. Explain the rationale for regulating body temperature in patients with cerebral disorders.

Regulating body temperature is important to patients with cerebral disorder since in any
case that there would be an increase in body temperature there would also be an increase
in the metabolic demand of the brain as well as it could lead to an increase in the rate of
forming cerebral edema. Furthermore the patient is observed for shivering (which should be
prevented) since it is connected with increased oxygen consumption, increase level of
circulating catecholamine, and increase vasoconstriction which could lead to brain
deterioration.

7. Describe the nursing management of a patient during a seizure.

The following are the management the nurse should render to a patient who experience
seizure:
a. Patient’s Safety
Patients safety is vital to patient who experience seizure it is achieve through
removing all harmful objects from the patients surrounding, furthermore if possible
ease the patient to the floor and place a pillow to the patients head, in the absence
of the pillow or any supporting materials use the hands of the nurse (or any person
who is available) to cushion the patients head. If the patient is on bed remove all
pillows and raise the side rails.
Do not attempt to restrain the patient during seizure since it could only lead to
injury since there is an increase muscular contraction during seizure. Do not
 attempt to forcefully open the jaws of the patient when it is clenched in a spasm or
insert anything for it may lead to a broken teeth and injury to the lips and tongue
of the patient.
If possible place the patients head to side with head flexed forward to facilitate
drainage of mucus and saliva.

b. Privacy
Patient’s privacy is also important during seizure attacks it is attain by protecting
from conscious onlookers. If possible if the patient shows warning signs of seizure
there could be a time to seek for a safe and private place.

c. Proper Documentation
It is also the responsibility of the nurse to document the duration, the type of
movements, the areas of the body involved and behaviors before and after the
seizure.

8. Describe the role of the nurse after a seizure has occurred.

The following are the management the nurse should render to a patient after seizure:
a. Place the client on a side-lying position to prevent complications and to facilitate
drainage of oral secretions if possible to maintain patent airway and prevent
aspiration.
b. Reorient the patient to the environment after the seizure.
c. Record the events that leads to and occurring during after the seizure to prevent
complications
d. It is an important responsibility of the nurse to have an health education to a client
about the importance of medication regimen

9. Describe the pathophysiology, clinical manifestations, and medical/nursing interventions for

epilepsy

Epilepsy is a group of syndromes characterized by unprovoked, recurring seizures. It means that

if a patient experience more than one attack of seizure it is already considered epilepsy.

a. Pathophysiology
Disturbance in the nerve cells excessive electrical firing  body parts perform
erratically
b. Clinical Manifestations
o Simple staring episodes (absence seizure)
o Prolong convulsive movements
 SIMPLE PARTIAL SEIZURE:
o Shake of finger or hand
 o Mouth jerk
o Dizziness
o Talk unintelligibly
o Unusual or unpleasant sights, sounds, odor or taste
 COMPLEX PARTIAL SEIZURE
o Either motionless or moves automatically and inappropriate
o Excessive emotional fear, elation or anger
 GENERALIZED
o Intense body rigidity
o Alternating muscle relaxation and contraction
o Incontinence

c. Medical Management
 Individualized care
 Pharmacologic therapy (ANTISEIZURE)
o Phenytoin (dilantin)
o Carbamazepine
o Phenobarbital
d. Nursing Interventions
o Preventing injury (priority)
o Reducing fear of seizure
o Improving coping mechanism
o Providing patient and family education

10. Describe the clinical manifestations of a migraine headache from prodrome phase to recovery
phase.

Clinical manifestation of migraine can be divided into the following phases:

1. Prodrome Phase
It refers to the symptoms that occur for hours to days before a migraine headache.
2. Aura Phase
This phase usually occurs for less than 60 minutes and it is characterized by focal
neurologic symptoms, visual disturbance, numbness, confusion, dizziness and
drowsiness.
3. Headache Phase
It occurs from 4 to 72 hours which is associated with photophobia, nausea and vomiting.
4. Recovery Phase
It is also refers to termination or postdrome phase. At this phase the pain gradually
subsides, while scalp and neck contraction is common with associated muscle ache.
During this phase the patient may also fall asleep.