Altered Mental Status PDF

Altered Mental Status The Gears aren’t Turning Dr. Ria A. DelloStrito Nurs 4043  Altered Mental Status A disruption in Wakefulness, or Arousal Controlled by the Reticular Activating System Can be affected by bilateral hemisphere alterations Consciousness Affected by...

Altered Mental Status The Gears aren’t Turning Dr. Ria A. DelloStrito Nurs 4043  Altered Mental Status A disruption in Wakefulness, or Arousal Controlled by the Reticular Activating System Can be affected by bilateral hemisphere alterations Consciousness Affected by alteration in Cerebral Cortex Persistent Vegetative State Can be awake, but has not cortical function How Do We Assess this Patient? “When we read, we begin with Check them! ABC” BP, HR, Cardiac Rhythm Check for Oxygen Level – SpO2 – give O2 if low alteration in: Glucose Level – finger Stick Check Opioids (Give Narcan) medications Benzo (Give Romazicon) given: What Else are we Going to Assess? Level of Glascow Coma Pupillary Motor Consciousness Scale Assessment Assessment AVPU = Alert, Best Motor Eye NIH Stroke Voice, Pain, Best Verbal movement/Pu Scale Unresponsive Best Eye pil reaction Opening Generalized vs Focal Findings Generalized/Global Findings Focal Findings Systemic cause More likely neurologic Depressed level of cause consciousness May or may not have Bilateral extremity depressed LOC weakness Unilateral extremity Symmetrical pupils weakness May have slurred speech May have facial droop May have slurred speech or aphasic Level of Consciousness: Alteration in Alertness/Mentation/Language Lethargy A stimulus will wake up the patient Obtundation Needs constant stimulation to stay awake Stupor Cannot stay awake even with stimulus Coma Does not awaken even with painful stimuli Level of Consciousness: Alteration in Alertness/Mentation/Language Orientation Name, Place, Time, and Purpose Knowledge of Current Events Caution: Many pts may be able to answer but are still confused. Language Expressive, Receptive, or Global Aphasia disorders of comprehension, fluency, naming and/or writing Dysarthria: slurred speech coordination problems of breath, vocal cords, larynx, palate, tongue, and/or lips Dysphonia difficulty with voice production (secondary to a Head/Neck or cranial nerve problem) Glascow Coma Scale Score based on the best score Can’t be higher than 15 or less than 3 Noxious stimuli must be administered Centrally not peripherally Based on Eye opening Verbal Motor (UE) Eye Assessment Eye Movement Pupillary Assessment Gazes: eyes deviate The baseline examination is the most important toward a lesion Size Eyes deviate away form Shape hemiparesis Symmetry Nystagmus: involuntary Reaction to light movements of the eyes Direct light reflex Consensual light reflex Accommodation CN III Oculomotor Nerve Resides in the Dorsal Midbrain Vulnerable to compression Controls several muscle around the eye Eye movement up, down, left, right Ciliary Muscle – Lens shape, focus on close up objects Sphincter pupillae – constricts pupil Pupil Size Pin-Point Miosis Opioids Mid-position Normal is Bilateral Dilated Mydriasis CN III Damage Pupil Shape Round Normal Ovid Increased ICP Early Herniation Keyhole Post Cataract Surgery Symmetry Anisocoria Unequal pupils 15% population Rarely more than 1mm difference Never greater in light than in dark Without ptosis Upper eyelid drooping All unsymmetrical pupils must be evaluated especially if this is a change from baseline!! Oculomotor nerve compression Constriction defect Eye does not respond to light R/T compression of nerve Cerebral Edema Uncal herniation Motor Assessment Range of motion, strength, coordination, and sensation. Strength each limb +5 - full ROM, full strength +4 - full ROM, less than normal strength +3 - can raise extremity but not against resistance +2 - can move extremity but not lift it +1 - slight movement/muscle twitch 0 - no movement/ no muscle contraction  Trapezius Central vs squeeze, Supraorbital pressure, sternal Peripheral rub. Stimulation Reflex response Motor vs true motor activity Assessment If no Gait and Coordination movement – Must Deliver Stimulus Check for Arms stretched out fully extended at pronation and shoulder level palms up. See if drift palms turns in and /or drifts down  LOC NIH Ability to Follow Commands Stroke Assessment of gaze Scale Assessment of Visual Fields The Presence of Facial Palsies Higher Test Movement and strength in all four limbs the Look for Limb ataxia-unsteady movements Score, Assess sensation the worse Assess Language the Dysarthria-slurred speech stroke Neglect https://www.mdcalc.com/calc/715/nih-stroke-scale-score-ni hss F.A.S.T Sodium Abnormalities Hyponatremia Hypovolemic Euvolemic Hypervolemic Hypernatremia S/S:AMS, seizures, coma What water does to the brain? What salt does to the brain? Replacing too fast –Central pontine myelinolysis  Acute confusional state/Delerium Symptoms develop quickly over short period of time Reduced ability to maintain attention Disorganized thinking Delirium vs Rambling speech, Perceptual disturbances-illusions, Dementia hallucinations, misinterpretations Disorientation Cognitive impairment- Dementia Progressive decline in cognitive function d/t damage or dz in brain.  Mania Neurotransmitter dysfunction CNS process Causes Systemic dx Toxins/meds of Infections Delirium Hypoxia Severe urinary retention Drug withdrawal Electrolyte abnormalities  CVA ICH Neurologi cal Pupillary changes Emergenc Status epilepticus ies Spinal cord compression Head trauma  Wernicke’s: acute mental confusion, ataxia, and ophthalmoplegia Thiamine deficiency in alcoholics Anoxic Hepatic Encephalopathi es Hypertensive Uremic Toxic Diabetic Questions?