Nursing: Unconscious Patient Care
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Questions and Answers

What is the preferred route for measuring body temperature in an unconscious patient?

  • Axillary
  • Ear canal
  • Mouth
  • Rectal or tympanic (correct)

    • Why is mouth temperature measurement not used in an unconscious patient?

  • It is not a reliable method
  • It is time-consuming
  • It is contraindicated in unconscious patients (correct)
  • It is less accurate

    • What is a potential complication of altered level of consciousness?

  • Pneumonia (correct)
  • Diabetes
  • Asthma
  • Hypertension

    • What is a major nursing goal for the patient with altered level of consciousness?

    <p>To compensate for the patient's loss of protective reflexes</p> Signup and view all the answers

    What is a goal of nursing interventions for the patient with altered level of consciousness?

    <p>To maintain the patient's clear airway</p> Signup and view all the answers

    What is a potential consequence of altered level of consciousness if not properly managed?

    <p>Respiratory distress</p> Signup and view all the answers

    What is the earliest sign of increasing ICP?

    <p>A change in LOC</p> Signup and view all the answers

    What is the normal range of cerebral perfusion pressure (CPP)?

    <p>70 to 100</p> Signup and view all the answers

    What is the purpose of burr holes in neurosurgical procedures?

    <p>To provide access to ventricles or for shunting procedures</p> Signup and view all the answers

    What is the result of a CCP of less than 50?

    <p>Permanent neurologic damage</p> Signup and view all the answers

    What is the purpose of craniotomy?

    <p>All of the above</p> Signup and view all the answers

    What is the purpose of cranioplasty?

    <p>To repair a cranial defect using a plastic or metal plate</p> Signup and view all the answers

    What is the goal of frequent monitoring of respiratory status and lung sounds?

    <p>To maintain a patent airway</p> Signup and view all the answers

    What is the purpose of elevating the head of the bed (HOB) to 0 to 60 degrees?

    <p>To promote venous drainage</p> Signup and view all the answers

    What is the purpose of avoiding hip flexion, Valsalva maneuver, abdominal distention, or other stimuli?

    <p>To avoid increasing ICP</p> Signup and view all the answers

    What is the purpose of using strict aseptic technique for management of ICP monitoring system?

    <p>To avoid infection</p> Signup and view all the answers

    What is the primary purpose of maintaining the patient's dignity and privacy?

    <p>To ensure patient's comfort and respect</p> Signup and view all the answers

    What is the recommended angle of elevation for the head of bed to promote accumulation of secretions and prevent obstruction of upper airway?

    <p>30 degrees</p> Signup and view all the answers

    What is the purpose of frequent turning and use of splints, foam boots, and trochanter rolls in maintaining tissue integrity?

    <p>To prevent skin breakdown and maintain correct body alignment</p> Signup and view all the answers

    What is the role of acetaminophen in maintaining body temperature?

    <p>To reduce fever</p> Signup and view all the answers

    What is the primary purpose of assessing fluid status by examining tissue turgor and mucosa?

    <p>To identify potential dehydration and electrolyte imbalances</p> Signup and view all the answers

    What is the purpose of using a bladder training program for the patient with altered level of consciousness?

    <p>To prevent urinary retention and incontinence</p> Signup and view all the answers

    What is the result of increased intracranial pressure (ICP) on cerebral perfusion?

    <p>It decreases cerebral perfusion</p> Signup and view all the answers

    What is the role of CO2 in autoregulation of cerebral blood flow?

    <p>It increases vasodilation</p> Signup and view all the answers

    What is the purpose of suctioning and oral hygiene in maintaining the patient's airway?

    <p>To prevent respiratory complications and maintain a patent airway</p> Signup and view all the answers

    What is the recommended frequency of monitoring temperature in patients with altered level of consciousness?

    <p>Frequently, but the exact frequency is not specified</p> Signup and view all the answers

    What is the primary purpose of burr holes in neurosurgical procedures?

    <p>To make a bone flap in the skull, aspirate a brain abscess, and evacuate a hematoma</p> Signup and view all the answers

    Which preoperative diagnostic procedure is used to assess blood flow in the brain?

    <p>Transcranial Doppler flow studies</p> Signup and view all the answers

    What is the purpose of giving corticosteroids, fluid restriction, and hyperosmotic agents preoperatively?

    <p>To reduce cerebral edema</p> Signup and view all the answers

    What is a major goal of care for the patient undergoing intracranial surgery?

    <p>Improving tissue perfusion</p> Signup and view all the answers

    What is the purpose of monitoring ABGs in the patient undergoing intracranial surgery?

    <p>To monitor respiratory function</p> Signup and view all the answers

    What is a potential complication of intracranial surgery?

    <p>All of the above</p> Signup and view all the answers

    What is the purpose of maintaining cerebral perfusion in the patient undergoing intracranial surgery?

    <p>To improve tissue perfusion</p> Signup and view all the answers

    What is a nursing intervention to regulate temperature in the patient undergoing intracranial surgery?

    <p>Covering patient appropriately</p> Signup and view all the answers

    What is not an indication of CSF leakage?

    <p>Vomiting</p> Signup and view all the answers

    What is a nursing intervention to enhance self-image in the patient undergoing intracranial surgery?

    <p>Encouraging verbalization and social interaction</p> Signup and view all the answers

    What is a symptom of CSF leakage?

    <p>Clear fluid draining from the nose</p> Signup and view all the answers

    What type of seizure originates in one hemisphere?

    <p>Focal</p> Signup and view all the answers

    What is a cause of seizures?

    <p>Cerebrovascular disease</p> Signup and view all the answers

    What is a type of primary headache?

    <p>All of the above</p> Signup and view all the answers

    What is a nursing intervention for a patient experiencing a seizure?

    <p>Observation and documentation of patient signs and symptoms</p> Signup and view all the answers

    What is the goal of nursing management of headache?

    <p>To identify triggers and develop preventive strategies</p> Signup and view all the answers

    What is a comfort measure for headache?

    <p>Quiet, dark room</p> Signup and view all the answers

    What is a type of secondary headache?

    <p>Headache caused by a brain tumor</p> Signup and view all the answers

    What is an important aspect of a headache evaluation?

    <p>Medication history</p> Signup and view all the answers

    What is a nonpharmacologic therapy for headache?

    <p>All of the above</p> Signup and view all the answers

    Study Notes

    Body Temperature Measurement

    • In unconscious patients, body temperature is never taken orally (mouth)
    • Rectal or tympanic (if not contraindicated) temperature measurement is preferred over axillary temperature

    Collaborative Problems and Potential Complications of Patients with Altered Level of Consciousness

    • Respiratory distress or failure
    • Pneumonia
    • Aspiration
    • Pressure ulcer
    • Deep vein thrombosis (DVT)
    • Contractures

    Goals for the Patient with Altered Level of Consciousness

    • Maintenance of clear airway
    • Protection from injury
    • Attainment of fluid volume balance
    • Maintenance of skin integrity
    • Absence of corneal irritation
    • Effective thermoregulation
    • Accurate perception of environmental stimuli
    • Maintenance of intact family or support system
    • Absence of complications

    Nursing Interventions for the Patient with Altered Level of Consciousness

    • Compensation for loss of protective reflexes
    • Assumption of responsibility for total patient care
    • Earliest sign of increasing ICP is a change in LOC
    • Slowing of speech and delay in response to verbal suggestions are other early indicators

    Cerebral Response to ICP

    • Cerebral perfusion pressure (CPP) is closely linked to ICP
    • CPP = MAP (mean arterial pressure) – ICP
    • Normal CPP is 70 to 100
    • A CPP of less than 50 results in permanent neurologic damage

    Early Manifestations of Increased ICP

    • Changes in LOC
    • Restlessness, confusion, increasing drowsiness, increased respiratory effort, purposeless movements
    • Pupillary changes and impaired ocular movements
    • Weakness in one extremity or one side
    • Headache: constant, increasing in intensity, or aggravated by movement or straining

    Late Manifestations of Increased ICP

    • Respiratory and vasomotor changes
    • VS: Increase in systolic blood pressure, widening of pulse pressure, and slowing of the heart rate
    • Temperature increase
    • Cushing triad: bradycardia, hypertension, bradypnea
    • Projectile vomiting
    • Further deterioration of LOC; stupor to coma
    • Hemiplegia, decortication, decerebration, or flaccidity
    • Respiratory pattern alterations including Cheyne–Stokes breathing and arrest
    • Loss of brainstem reflexes: pupil, gag, corneal, and swallowing

    Assessment of the Patient with Increased Intracranial Pressure

    • Obtain history of events leading to illness
    • Evaluate mental status, LOC
    • Assessment of selected cranial nerves
    • Assess cerebellar function, reflexes, motor and sensory function
    • Glasgow Coma Scale, pupil checks
    • Frequent vital signs
    • Assessment of intracranial pressure

    ICP Monitoring

    • Location of the Foramen of Monro for Calibration of ICP Monitoring System

    Collaborative Problems and Potential Complications of the Patient with Increased Intracranial Pressure

    • Brainstem herniation
    • Diabetes insipidus
    • SIADH

    Goals for the Patient with Increased Intracranial Pressure

    • Maintenance of patent airway
    • Normalization of respirations
    • Adequate cerebral tissue perfusion
    • Fluid balance
    • Absence of infection
    • Absence of complications

    Nursing Interventions for the Patient with Increased Intracranial Pressure

    • Frequent monitoring of respiratory status and lung sounds
    • Measures to maintain a patent airway
    • Position with head in neutral position and elevation of HOB 0 to 60 degrees to promote venous drainage
    • Avoid hip flexion, Valsalva maneuver, abdominal distention, or other stimuli that may increase ICP
    • Maintain a calm, quiet atmosphere and protect patient from stress
    • Monitor fluid status carefully; every hour I&O during acute phase
    • Use strict aseptic technique for management of ICP monitoring system

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    Description

    Test your knowledge of nursing care for unconscious patients. This quiz covers body temperature measurement routes and other collaborative problems.

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