Alterations in Cognition and Sensation

1
Alterations in Cognition and Sensation

• Read Ignatavisius Workman
• Ch. 44, 45(p.946-59),46(998-03),
• 47 (1006-18),49, 50(1092-96,1102-06) 51,
  52(1127-28)

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Decreased LOC

• Manifestations
• LOC
• Breathing Pattern
• Eye Movement
• Motor Response
• Vital Signs
• Cushings Triad

3
Decreased LOC

• Diagnostic Tests
• CT
• MRI
• EEG
• Lumbar Puncture
• Angiogram

4
Nursing Care

• Assessment
• Glasgow Coma Scale
• Nursing Care Plan
• Ineffective Airway Clearance/Breathing Pattern
• Altered Cerebral Tissue Perfusion
• Altered Nutrition
• Impaired Skin Integrity
• Risk for Infection
• Self-Care Deficit

5
Headaches

• Types
• Migraine
• Cluster
• Tension
• Medical Management
• Pharmacological
• Nursing Care Plan
• Acute Pain

6
Seizure Disorder

• Epilepsy
• S/S
• Partial Seizure (Focal, Local)
• Generalized
• Myoclonic
• Tonic-Clonic
• Medical Management
• Anti-convulsants - Dilantin,Depakene, Klonopin

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Nursing Care

• Ineffective Breathing Pattern
• Ineffective Airway Clearance
• Risk for Injury
• Ineffective Individual Coping

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Client with Seizures

• A young woman is admitted to the ASU with a
  history of seizures. As you are assessing her,
  she tells you she is about to have a seizure
• How does she know she is going to have a seizure?
• What should you do in response to her statement?

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• What is the primary difference between
  generalized tonic-clonic and myoclonic seizures?
• Why is the client at risk for injury following a
  generalized seizure?

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Neurological Degenerative Disorders

• Multiple Sclerosis
• S/S - weakness, visual disturbances/loss,
  fatigue,emotional lability, dysphagia,
  incoordination, bowel/bladder dysfunction
• Management
• Pharmacolocical - corticosteroids, Betaseron,
  Oxybutinen, Baclofen

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Multiple Sclerosis

• Nursing Care Plan
• Impaired Physical Mobility
• Self Care Deficit
• Sensory/Perceptual Alteration
• Constipation

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Client with MS

• A home health nurse is interviewing a 24 yr old
  client with newly diagnoses MS. She is upset over
  her increasing loss of mobility, decreased visual
  acuity and the severe fatigue that worsens as the
  day progresses. The client states she is
  experiencing mood swings she cant control. She
  wants to start a family but now this is on hold

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• What initial assessments should the nurse make in
  regard to her diagnosis?
• What actions should the nurse take to help the
  client increase mobility and lessen fatigue?
• What instructional materials and recommendations
  should the nurse leave with the client and her
  husband?

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Myasthenia Gravis

• S/S
• increasing weakness w/sustained msucle
  contraction, respiratory complications
• IV Tensilon - improves muscle strength - DX
• Medical TX
• cholinesterases, steroids
• Myasthenia Crisis

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Myasthenia Gravis

• Nursing Care Plan
• Ineffective Breathing Pattern
• Ineffective Airway Clearance
• Impaired Verbal Communication
• Altered Nutrition
• Activity Intolerance
• Sensory/Perceptual Alteration

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Client with Myasthenia Gravis

• A 66 year old man is recovering from myasthenia
  crisis during which time he suffered respiratory
  distress requiring mechanical ventilation for
  several days. The care provider believes an
  earlier episode of gastroenteritis triggered the
  crisis

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• What is myasthenia gravis and what symptoms most
  likely prompted the client to seek medical
  attention?
• Why is the clients earlier episode with
  gastroenteritis suspected to be the trigger?
• Why is it necessary to teach the client to
  recognize cholinergic crisis?
• What are the desired outcomes for this pt.?

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Guillian-Barre Syndrome

• S/S
• ascending weakness, resp. muscle
  weakness,paralysis
• Complications
• resp. failure, hypotension, urinary retention,
  dysrhythmias

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Guillian-Barre Syndrome

• Nursing Care Plan
• Ineffective Breathing Pattern
• Risk for Aspiration
• Pain
• Impaired Verbal Communication
• Fear
• Self Care Deficit

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Cerbrovascular Accident

• Causes - occlusion, hemorrhage
• TIAs
• S/S
• Acute Care
• anticoagulants, antiplatelets
• steroids, osmotic diuretics
• seizure control
• prevent aspiration
• Assess LOC,ICP,Glasgow Coma Scale

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Nursing Care Plan

• Altered Cerebral Tissue Perfusion
• Impaired Physical Mobility
• Impaired Verbal Communication
• Self-care Deficit
• Sensory/Perceptual Deficit
• Alteration in Urinary Elimination
• Constipation
• Ineffective Airway Clearance
• Impaired Swallowing

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Client with CVA

• A 72 year old woman is admitted to the acute care
  facility after her family finds her in an
  unconscious state early this morning. The
  assessment reveals no history of hypertension or
  other health problems. She complained of a
  headache on the day prior to admission.
  VS-150/96,56,16,101degrees, Glasgow Coma Scale
  -5. DX- CVA

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• Prioritize the following nsg interventions
• Monitor Temp
• Assess neurological status
• Assess respiratory status
• Elevate HOB to 45 degrees(High Fowlers)
• The client begins to seize as her condition
  worsens. ID 3 nursing interventions essential at
  this time.

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• What signs, other than seizures, should alert the
  nurse the client is developing increased
  intracranial pressure (ICP)?
• After determining the client has suffered
  extensive cerebral damage, the health care
  provider writes a DNR order per family request.
  List 3 appropriate nursing interventions at this
  time.

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Infection of Nervous System

• Meningitis
• S/S - HA, fever/chills, N/V, stiff neck, back
  pain
• Management
• emergency - IV ATB X 10 days
• Nursing Care
• Assess Neuro status
• Respiratory isolation
• treat seizures
• pain relief - neck
• decrease stimulation

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Encephalitis

• S/S - meningeal irritation
• seizures,confusion, stupor - coma, aphasia
• Causes
• Poliomyolitis
• Cause - polio virus
• destroys motor cells in spinal cord

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Client with Meningitis

• A 21 year old college student was taken to the ER
  after her roommate found her lying with her right
  thigh flexed up toward her abdomen and
  complaining of a severe headache and stiff neck.
  Initial assessment by the nurse revealed a
  positive Kernigs sign and positive Brudzinskis
  sign. Bacterial meningitis is suspected.

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• What is the significance of the positive Kernig
  and Brudzinski signs?
• What other signs should the nurse assess for in
  order to confeirm the presence of bacterial
  meningitis?

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• What actions will the nurse take after assessing
  the client?
• How does the clinical presentation of septic
  (bacterial) meningitis differ from aseptic
  (viral) meningitis?

30
Brain Tumor

• S/S - ICP
• HA, N/V, papilledema, seizures, dizziness,
  vertigo
• Medical Management
• chemotherapy, radiation, palliative
• Nursing Care
• Altered Cerebral Perfusion

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Problems with Sensation

• Retinal Detachment
• S/S - visual changes
• Surgical Repair - Scleral Buckling
• Nursing Care
• assess for drainage
• positioning
• eye drops
• activity restrictions

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Cataracts

• S/S - blurred vision, diplopia, photophobia,
  glare
• Treatment
• Cataract extraction
• Nursing Care - patient education