LEARNING ACTIVITY SHEET

(FINAL TERM-LECTURE-NCM 118)

TOPIC: MANAGEMENT OF CRITICALLY ILL PATIENTS WITH ALTERED PERCEPTION

LEARNING OUTCOMES:
Given an actual client with maladaptive patterns of behaviors, students will be able to:
1. Prioritize needs of the individual with complex neurological deficits.
2. Perform accurate components of the neurological assessment.
3. Identify changes in neurological status of the individual experiencing neurological
compromise.
4. Provide comprehensive nursing management of the individual with altered perception
5. Define key diagnostic tools used to collaborate neurological trauma or debility. 6. Use a
case study scenario to apply learned skills while caring for a patient
7. with complex neurological needs.

LEARNING TASK 1
Case Scenario:
Maria Antonette the Pooh, an 80-year-old pleasantly smiling lady arrives independently to the
Emergency Unit with the chief complaints of “double vision, severe and worsening headache for
1 week.” She is awake, alert, and admits to no recent falls or injuries. She has been taking
antihypertensive medications for the past 20 years. Vital signs are T: 100, P: 84, R: 16, and BP:
150/80. Within minutes of her initial assessment, the patient’s condition begins to rapidly decline.
Vital signs are now T: 101.8, P: 70, R: 12, and BP: 210/60. The patient’s gaze is now dysconjugate
and verbal responses to questions and commands are nonexistent. Vital signs indicate Cushing’s
triad, with a widening pulse pressure of 150. Calia Lily, her daughter arrives and provides the
information that 1 week ago, as her mother was cleaning an expensive chandelier, she fell off of
her dining room table and struck her head on a corner of the table.
QUESTIONS
What additional nursing considerations and interventions would be indicated and why? Explain
and discuss.
By closely monitoring patients who may be at risk of raised ICP, we can detect any changes
promptly and therefore improve patient outcomes with early treatment interventions.
The nurse must monitor and report any early signs and symptoms of increasing ICP, which can
be done by regularly attending to neurological observations on the patient. These signs include:
• Disorientation, restlessness, mental confusion and purposeless movements;
• Pupillary changes and impaired extraocular movements;
• Weakness in one extremity or hemiplegia; and
• Headache, constant in nature, increasing in intensity and aggravated by movement or
straining.
If the patient’s condition progresses, the symptoms may worsen to:
 • Deterioration in level of consciousness;
• Cushing’s triad;
• Altered respiratory patterns including Cheyne-Stokes breathing;
• Vomiting;
• Hemiplegia; and
• Loss of brain stem reflexes (pupillary, corneal, gag and swallowing reflexes).
If a patient is suspected of having an increased ICP, methods to reduce the pressure from
increasing further include elevating the patient’s head to 30 degrees, keeping their neck in a
neutral position, avoiding overhydration, maintaining normal body temperature and maintaining
normal oxygen and carbon dioxide levels.
Increased ICP can be managed in many ways, including through medical and surgical
interventions. Nurses need to ensure they are assessing and monitoring patients for any potential
changes to ICP and reporting these changes promptly in order for early interventions to be
implemented and patient outcomes to be improved.

LEARNING TASK 2
Instructions: Give the following nursing considerations/instructions in implementing the
following diagnostic exam. Explain.
Diagnostic Assessment
Brain Imaging (CT, MRI, PET)
Nursing Considerations
1. The patient is placed in
a supine position on a narrow,
padded, nonmetallic bed that slides
to the desired position inside the
scanner.
2. The patient is asked to remain still.
3. Radiofrequency energy is directed
at the area being tested. The
radiologist may vary the waves and
use the computer to manipulate and
enhance the images.
4. The resulting images are displayed
on a monitor and recorded on film
or magnetic tape for permanent
storage.
5. The patient is advised to keep his
eyes closed to promote relaxation
and prevent a closed-in-feeling.
6. If nausea occurs because of
claustrophobia, the patient is
encouraged to take deep breaths.
7. If the test is prolonged with the
patient lying flat, monitor him for
orthostatic hypotension.
8. Explain to the patient the purpose of
the test. Tell him who will perform
the test and where it will take place.
9. Inform the patient that he’ll need to
lie flat on a narrow bed, which
slides into a large cylinder that
houses the MRI magnets. Tell him
that the scanner will make clicking,
whirring, and thumping noises as it
moves inside its housing and that he
may receive earplugs.
10. Explain to the patient that MRI is
painless and involves no exposure
to radiation from the scanner. A
radioactive contrast dye may be
used, depending on the tissue being
studied.
11. For MRI of the urinary tract, advise
the patient to avoid alcohol,
caffeine-containing beverages, and
smoking for at least 2 hours and
food for at least 1 hour before the
test. Explain to the patient that he
can continue taking medications,
except for iron, which interferes
with the imaging.
12. Advise the patient that he’ll have to
remain still for the entire
procedure.
13. Explain to the patient who’s
claustrophobic or anxious about the
test’s duration that he’ll receive a
mild sedative to reduce his anxiety
or that he may need to be scanned
in an open MRI scanner, which may
take longer but is less confining. Tell
him that he’ll be able to
communicate with the technician at
all times and that the procedure will
be stopped if he feels
claustrophobic.
14. If contrast media will be used,
obtain a history of allergies or
hypersensitivity to these agents.
Mark any sensitivities on the chart
and notify the practitioner.
15. Instruct the patient to remove all
metallic objects, including jewelry,
hairpins, and watches.
16. Ask the patient if he has any
implanted metal devices or
prostheses, such as vascular clips,
 shrapnel, pacemakers, joint
implants, filters, and intrauterine
devices. If so, the test may not be
able to be performed.
17. Make sure that the patient or a
responsible family member has
signed an informed consent form.
18. Administer the prescribed sedative
if ordered.
19. At the scanner room door, recheck
the patient one last time for metal
objects.
20. Just before the procedure, have the
patient urinate.
21. Remind the patient to remain still
throughout the procedure.
22. Assess how the patient responds to
the enclosed environment. Provide
reassurance if necessary.
23. Monitor the cardiac function for
signs of ischemia (chest pressure,
shortness of breath, or changes in
hemodynamic status).
24. If the patient is unstable, make sure
an IV line with no metal
components is in place and that all
equipment is compatible with MRI.
If necessary, monitor the patient’s
oxygen saturation, cardiac rhythm,
and respiratory status during the
test. An anesthesiologist may be
needed to monitor a heavily sedated
patients. Remind the patient to
remain still throughout the
procedure.
25. Assess how the patient responds to
the enclosed environment. Provide
reassurance if necessary.
26. Monitor the cardiac function for
signs of ischemia (chest pressure,
shortness of breath, or changes in
hemodynamic status).
27. If the patient is unstable, make sure
an IV line with no metal
components is in place and that all
equipment is compatible with MRI.
If necessary, monitor the patient’s
oxygen saturation, cardiac rhythm,
and respiratory status during the
test. An anesthesiologist may be
needed to monitor a heavily sedated
patients.
Cerebral Angiography 1. Make arrangements for
transportation home following the
procedure. Patients are not
permitted to drive after a cerebral
angiogram.
2. Do not eat or drink after midnight
the night before the test.
3. Patients who take medications
routinely should check with their
physician. If routine medication is
allowed the day of the test, it should
only be taken with a small sip of
water.
4. Leave all valuables at home.
5. Inform the angiogram technician if
pregnant or breast-feeding. Also
inform the technician of any of the
following conditions: asthma,
diabetes, and allergies to iodine,
shellfish, drugs, or latex.
6. Make arrangements for
transportation home following the
procedure. Patients are not
permitted to drive after a cerebral
angiogram.
7. Do not eat or drink after midnight
the night before the test.
8. Patients who take medications
routinely should check with their
physician. If routine medication is
allowed the day of the test, it should
only be taken with a small sip of
water.
9. Leave all valuables at home.
10. Inform the angiogram technician if
pregnant or breast-feeding. Also
inform the technician of any of the
following conditions: asthma,
diabetes, and allergies to iodine,
shellfish, drugs, or latex.
11. Make arrangements for
transportation home following the
procedure. Patients are not
permitted to drive after a cerebral
angiogram.
12. Do not eat or drink after midnight
the night before the test.
13. Patients who take medications
routinely should check with their
 physician. If routine medication is
allowed the day of the test, it should
only be taken with a small sip of
water.
14. Leave all valuables at home.
15. Inform the angiogram technician if
pregnant or breast-feeding. Also
inform the technician of any of the
following conditions: asthma,
diabetes, and allergies to iodine,
shellfish, drugs, or latex.
16. While the patient is in the
observation area, nurses check vital
signs, the incision site, and attend to
all of the patient’s needs. It is
necessary for the patient to lie still
with his or her head flat for six to
eight hours. Gradually the patient is
allowed to get out of bed with
assistance; lightheadedness and
dizziness may occur if the patient
gets out of bed too quickly.
17. When the patient is released home,
he or she is given discharge
instructions. These ‘at home’
instructions include:
18. No heavy lifting, exercise, and
driving for 48 hours. Do not operate
machinery for at least 24 hours. It is
important not to stress the
incision/puncture site.
19. During the next 24 hours, drink
plenty of fluids to flush the contrast
dye from the kidneys. Avoid
beverages that dehydrate the body,
such as alcohol or coffee.
20. Resume a regular diet.

Cerebral Perfusion ▪ When patient experiences dizziness

due to orthostatic hypotension when
getting up, educate methods to
decrease dizziness, such as remaining
seated for several minutes before
standing, flexing feet upward several
times while seated, rising slowly, sitting
down immediately if feeling dizzy, and
trying to have someone present when
standing.
▪ Check mental status; perform a
neurological examination.
 ▪ Avoid measures that may trigger
increased ICP such as coughing,
vomiting, straining at stool, neck in
flexion, head flat, or bearing down.
▪ If ICP is increased, elevate head of bed
30 to 45 degrees.
▪ Evaluate motor reaction to simple
commands, noting purposeful and
nonpurposeful movement. Document
limb movement and note right and left
sides individually.
ICP Monitoring By closely monitoring patients who may be at
risk of raised ICP, we can detect any changes
promptly and therefore improve patient
outcomes with early treatment interventions.

The nurse must monitor and report any early

signs and symptoms of increasing ICP, which
can be done by regularly attending to
neurological observations on the patient. These
signs include:

Disorientation, restlessness, mental confusion

and purposeless movements;
Pupillary changes and impaired extraocular
movements;
Weakness in one extremity or hemiplegia; and
Headache, constant in nature, increasing in
intensity and aggravated by movement or
straining.
(Farrell & Dempsey 2013)
If the patient’s condition progresses, the
symptoms may worsen to:

Deterioration in level of consciousness;

Cushing’s triad;
Altered respiratory patterns including Cheyne-
Stokes breathing;
Vomiting;
Hemiplegia; and
Loss of brain stem reflexes (pupillary, corneal,
gag and swallowing reflexes).
(Farrell & Dempsey 2013)

If a patient is suspected of having an increased

ICP, methods to reduce the pressure from
increasing further include elevating the
patient’s head to 30 degrees, keeping their
neck in a neutral position, avoiding
overhydration, maintaining normal body
temperature and maintaining normal oxygen
and carbon dioxide levels (Sippel 2011).

Pulse Wave Forms • Nurses must be able to:

o Identify key anatomical sites –
this makes it easier to access
 sites and maximizes the
potential for a safe assessment
o Obtain informed consent
o Ensure the patient is relaxed
and the relative position of the
chosen site is equal to, or lower
than, the level of the heart
• When assessing a patient’s pulse, the
following must always be documented:
o Time
o Pulse rate
o Pulse quality

CPP (Cerebral Perfusion)

1. Verify physician’s orders for
hourly ventricular drainage
parameters.
2. Maintain head of bed flat or
raised to a prescribed height as
ordered or depending on ICP
and CPP measurements. Clarify
head position with physician.
3. Maintain head and neck in
neutral position. Avoid
hyperflexion, hyperextension,
or severe rotation.
4. Verify the physician’s order for
insertion site dressing changes.
5. Maintain integrity as a closed
system.
6. Inspect the system for kinks
and leaks in the circuit.
7. Change drainage bag when the
drainage bag is 3/4 full or in
place for 72 hours (verify with
neurosurgeon). Mark drainage
bag with time and date.
Maintain aseptic technique. For
breaks in the sterile system,
notify MD.
8. Zero balance and calibrate the
system at least q 8 hr. and prn.
9. Set ICP alarms 10 mm Hg lower
and higher than the patient’s
usual range.
10. Secure endotracheal tubes in
ways that do not occlude
venous return to the head.
11. Suction patients for less than 10
seconds. If coughing occurs,
consider administering
lidocaine via the endotracheal
tube per MD order.
12. Space activities of daily living.
13. Decrease environmental
stimuli.
 14. Provide cooling measures to
maintain normal body
temperature.
15. Administer stool softener as per
physician order to prevent
constipation and straining.
16. Notify physician for:
a.
17. a. any changes in neurological
signs
b. elevated ICP and/or values
greater than 15 mm Hg. for 5
minutes or more
c. CPP greater than 100 mm Hg.
or less than 70 mm Hg.
d. temperature or WBC
elevation
e. CSF leakage
f. Change in CSF drainage
amount, color and clarity
g. malfunction of the
monitoring system.
18. Troubleshoot the ICP fluid
filled system for problems such
as:
a. breaks in the system
b. dampened waveform
c. loss of wave form
d.occlusion of tubing
e. change in CSF drainage amount
19. Administer sedation per MD
order
20. Minimize any increases in intra-
abdominal/intrathoracic
pressure (an increase in intra-
abdominal pressure may
require gastric decompression

Cerebral Oxygenation -Raise the Head of the Bed

-Encourage Enhanced Breathing and Coughing
Techniques
-Manage Oxygen Therapy and Equipment
-Assess the Need for Respiratory Medications
-Provide Oral Suctioning if Needed
-Provide Pain Relief If Needed
-Consider the Side Effects of Pain Medications
-Consider Other Devices to Enhance Clearance
of Secretions
-Plan Frequent Rest Periods Between Activities
-Consider Other Potential Causes of Dyspnea
-Consider Obstructive Sleep Apnea
Transcranial Doppler ▪ Position to prevent contractures;
use measures to relieve pressure,
assist in maintaining good body
alignment, and prevent compressive
neuropathies.
 ▪ Apply a splint at night to prevent
flexion of affected extremity.
▪ Prevent adduction of the affected
shoulder with a pillow placed in the
axilla.
▪ Elevate affected arm to prevent
edema and fibrosis.
▪ Position fingers so that they are
barely flexed; place hand in slight
supination. If upper extremity
spasticity is noted, do not use a
hand roll; dorsal wrist splint may
be used.
▪ Change position every 2 hours;
place patient in a prone position for
15 to 30 minutes several times a
day.
▪ Provide full range of motion four or five
times a day to maintain joint mobility,
regain motor control, prevent
contractures in the paralyzed
extremity, prevent further
deterioration of the neuromuscular
system, and enhance circulation. If
tightness occurs in any area, perform
rangeofmotion exercises more
frequently.
▪ Observe for signs of pulmonary
embolus or excessive cardiac workload
during exercise period (eg, shortness of
breath, chest pain, cyanosis, and
increasing pulse rate).
▪ Supervise and support patient during
exercises; plan frequent short periods
of exercise, not longer periods;
encourage patient to exercise
unaffected side at intervals throughout
the day.

EEG
• If the patient routinely takes seizure
medication to prevent
seizures, antidepressants, or
stimulants, he or she may be asked to
stop taking these medications 1 to 2
days before the test.
• The patient may be told not to
consume caffeine before the test.
• The patient should avoid using hair
styling products (hairspray or gel) on
the day of the exam.
• It is prudent to have someone take the
patient to the EEG location, especially if
he or she has been asked to stop taking
seizure medications.
 • If the patient is having a sleep EEG, he
or she may be asked to stay awake the
night before the exam.

Near Infrared Spectroscopy ▪ Explain the procedure to the client, and

that NIRS is a non- invasive surgery
▪ Position the client in an upright
position
▪ Assist for the placement of the cap
▪ Explain the client that it will take at
least 40 minutes to finish the
procedure and follow the instructions
given by the professional
▪ Instruct the client to not move the head
too much for accurate readings
LEARNING TASK 3. MY PLAN FOR YOU!
Instructions: Craft at least two Nursing Care Plan based on the Nursing Diagnoses listed below.
Follow the standard format set by the College. (see rubrics for scoring)
• Ineffective Cerebral Tissue Perfusion related to Decreased Cerebral Blood Flow
• Ineffective Cerebral Tissue Perfusion related to Hemorrhage
• Acute Pain related to Transmission and Perception of Cutaneous
• Unilateral Neglect related to Perceptual Disruption
• Impaired Verbal Communication related to Cerebral Speech Central Injury
A D P I R E
Subjective Ineffective Cerebral After 3 weeks of -Assess airway -Neurologic deficits After 3 weeks of
Tissue Perfusion nursing intervention patency and of a stroke may nursing intervention
She fell off of her
related to Goal The client will respiratory pattern. include loss of gag Goal The client was
dining room table
Decreased Cerebral be able to have an reflex or cough able to have an
and struck her head
Blood Flow effective cerebral reflex; thus, airway effective cerebral
on a corner of the
tissue perfusion patency and tissue perfusion
table.
breathing pattern
To assess To assess
must be part of the
contributing factors contributing factors
initial assessment.
To note degree of To note degree of
- Assess factors - The extensive
impairment impairment
related to decreased neurologic
To maximize tissue cerebral perfusion examination will To maximize tissue
perfusion and the potential for help guide therapy perfusion
increased and the choice of
intracranial interventions.
After 6weeks of pressure (ICP). After 6weeks of
nursing intervention nursing intervention
- Recognize the -Patients with TIA
the client will be the client was able
clinical present with
able to demonstrate to demonstrate
T: 100, P: 84, R: 16, manifestations of a temporary
increased perfusion increased perfusion
and BP: 150/80 transient ischemic neurologic
(e.g., vital signs (e.g., vital signs
attack (TIA). symptoms such as
• Disorientation, within normal range, within normal range,
alert/oriented, free sudden loss of alert/oriented, free
restlessness,
of pain/discomfort motor, sensory, or of pain/discomfort
mental
visual function
confusion and
caused by transient
purposeless
ischemia to a
movements;
specific region of the
• Pupillary brain, with their
changes and brain imaging scan
impaired
 extraocular - Frequently assess showing no evidence
movements; and monitor of ischemia.
neurological status.
• Weakness in - Assess trends in
one extremity the level of
or hemiplegia; consciousness
and (LOC), the potential
for increased ICP,
• Headache,
and helps determine
constant in
location, extent, and
nature,
progression of
increasing in
damage. Prognosis
intensity and
depends on the
aggravated by
neurologic condition
movement or
of the patient. It may
straining.
also reveal the
presence of TIA,
which may warn of
- Monitor changes in impending
blood pressure, thrombotic CVA.
compare BP
- Hypertension is a
readings in both
significant risk
arms.
factor for stroke.
Fluctuation in blood
pressure may occur
because of cerebral
injury in the
vasomotor area of
the brain.
Hypertension or
postural
hypotension may
have been a
precipitating factor.
Hypotension may
occur because of
shock (circulatory
 collapse), and
increased ICP may
occur because of
tissue edema or clot
formation.
Subclavian artery
blockage may be
revealed by the
difference in
- Monitor heart rate pressure readings
and rhythm, assess between arms.
for murmurs.

- Changes in rate,
especially
bradycardia, can
occur because of
brain damage.
Dysrhythmias and
murmurs may
reflect cardiac
disease,
precipitating CVA
(stroke after MI or
valve dysfunction).
- Monitor The presence of
respirations, noting atrial fibrillation
patterns and increases the risk of
rhythm, Cheyne- emboli formation.
Stokes respiration. - Irregular
respiration can
suggest the location
of cerebral insult or
increasing ICP and
the need for further
intervention,
- Monitor computed including possible
tomography scan. respiratory support.

- A CT scan is the
initial diagnostic test
performed for
patients with stroke
that is executed
immediately once
the patient presents
to the emergency
department. CT scan
is used to determine
if the event is
ischemic or
hemorrhagic as the
type of stroke will
guide therapy. A
computed
tomography
angiography (CTA)
may also be
performed to detect
intracranial
- Evaluate pupils, occlusions and the
noting size, shape, extent of occlusion
equality, light in the arterial tree.
reactivity.
- Pupil reactions are
regulated by the
oculomotor (III)
cranial nerve and
help determine
whether the brain
stem is intact. Pupil
size and equality are
determined by the
 balance between
parasympathetic
and sympathetic
innervation.
Response to light
reflects the
combined function
of the optic (II) and
- Document changes oculomotor (III)
in vision: reports of cranial nerves.
blurred vision,
alterations in the - Visual disturbances
visual field, depth may occur if the
perception. aneurysm is
adjacent to the
oculomotor nerve.
Specific visual
alterations reflect an
area of the brain
- Assess higher involved. Initiate
functions, including measures to
speech, if the patient promote safety.
is alert.
- Changes in
cognition and speech
content indicate
location and degree
of cerebral
involvement and
may indicate
- Assess for nuchal deterioration or
rigidity, twitching, increased ICP.
increased
restlessness,
irritability, the onset - Nuchal rigidity
of seizure activity. (pain and rigidity of
the back of the neck)
may indicate
meningeal irritation.
Seizures may reflect
an increase in ICP or
cerebral injury
requiring further
evaluation and
intervention.
A D P I R E
-Submit patient to -A variety of tests are
diagnostic testing as available depending on
indicated. the cause of the
impaired tissue
perfusion. Angiograms,
Doppler flow studies,
segmental limb
pressure measurement
such as ankle-brachial
index (ABI), and
vascular stress testing
are examples of these
tests.

- Sufficient fluid intake

- Check for optimal maintains adequate
fluid balance. filling pressures and
Administer IV fluids optimizes cardiac
as ordered. output needed for tissue
perfusion.

- Reduce renal perfusion

may take place due to
- Note urine output. vascular occlusion.
- This ensures adequate
perfusion of vital
organs.
- These facilitate
- Maintain optimal perfusion when
cardiac output. interference to blood
flow transpires or when
-Consider the need perfusion has gone
for potential down to such a serious
embolectomy, level leading to ischemic
heparinization, damage.
vasodilator therapy,
thrombolytic
therapy, and fluid - Orthostatic
rescue. hypotension results in
temporary decreased
cerebral perfusion.
- When patient
experiences
dizziness due to
orthostatic
hypotension when
getting up, educate
methods to decrease
dizziness, such as
remaining seated for
several minutes
before standing,
flexing feet upward
several times while
seated, rising slowly,
sitting down
immediately if
feeling dizzy, and
trying to have
someone present - Review trend in level
when standing. of consciousness (LOC)
and possibility for
increased ICP and is
helpful in deciding
- Check mental
location, extent and
status; perform a
development/resolution
neurological
or central nervous
examination.
system (CNS) damage.
- If ICP is increased, - This promotes venous
elevate head of bed outflow from brain and
30 to 45 degrees. helps reduce pressure.
- Avoid measures - These will further
that may trigger reduce cerebral blood
increased ICP such flow.
as coughing,
vomiting, straining
at stool, neck in
flexion, head flat, or
bearing down.
- Administer - These reduce risk of
anticonvulsants as seizure which may
needed. result from cerebral
edema or ischemia.

- Control
environmental - Fever may be a sign of
temperature as damage to
necessary. Perform hypothalamus. Fever
tepid sponge bath and shivering can
when fever occurs. further increase ICP.

- Evaluate eye - Establishes arousal

opening. ability or level of
consciousness.

- Evaluate motor
reaction to simple - Measures overall
commands, noting awareness and capacity
purposeful and non- to react to external
purposeful stimuli, and best
movement. signifies condition of
Document limb consciousness in the
movement and note patient whose eyes are
closed due to trauma or
right and left sides who is aphasic.
individually. Consciousness and
involuntary movement
are incorporated if
patient can both take
hold of and let go of the
tester’s hand or grasp
two fingers on
command. Purposeful
movement can comprise
of grimacing or
withdrawing from
painful stimuli. Other
movements (posturing
and abnormal flexion of
extremities) usually
specify disperse cortical
damage. Absence of
spontaneous movement
on one side of the body
signifies damage to the
motor tracts in the
opposite cerebral
hemisphere.

- Evaluate verbal - Measures

reaction. Observe if appropriateness of
patient is oriented to speech content and level
person, place and of consciousness. If
time; or is confused; minimum damage has
uses inappropriate taken place in the
words or phrases cerebral cortex, patient
that make little may be stimulated by
sense. verbal stimuli but may
show drowsy or
uncooperative. More
 broad damage to the
cerebral cortex may be
manifested by slow
reaction to commands,
lapsing into sleep when
not aroused,
disorientation, and
stupor. Injury to
midbrain , pons, and
medulla is evidenced by
lack of appropriate
reactions to stimuli.

- Provide rest - Constant activity can

periods between further increase ICP by
care activities and creating a cumulative
prevent duration of stimulant effect.
procedures.

- Reorient to
environment as - Decreased cerebral
needed. blood flow or cerebral
edema may result in
changes in the LOC.
Rubrics
Features 5 4 3 2 1
Focus/Analysis All key aspects Only modest Some Adequate in Weak
The single identified and abstraction potenti parts; gaps in the progression
controlling point is related beyond facts; al connections logical of
made with an overly missed development ideas
awareness of the derivative
task about a specific
topic.
Task achievement Fully addresses Sufficiently Presents a Presents Arranges
Fulfillment of the all parts of the addresses all clear position relevant information
task being task parts of the task but there may ideas but some and ideas but
presented by the be a tendency may be an
activity. that the inadequa unclear
supporting tely developed progression
ideas may lack
position
Relevance/ The task makes The task makes The task makes The task makes The task makes
Connections appropriate some unclear or undistinguishable no connections
Relation of the task connections appropriate inappropriate connections between the
to the between the connections connections between the purpose and
concepts/ideas purposes and between between the purposes and features of the
features of the the purposes and features of the ideas/concepts
ideas/concepts purposes features of the ideas/concepts
and ideas/concepts
features
of
the
ideas/concepts