Nursing 3910A/B Study Guide - Final Guide: Agraphia, Ascites, Diuresis
19 Mar 2019
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Document Summary
Altered level of consciousness: what can cause altered loc, alcohol, epilepsy. Is a continuum, manifestations depend on where the client is on the continuum. Arm moving, pronator drift: glasgow coma scale: measures neurological function, complications: all systems are at risk. Nursing interventions loc: family coping, assess loc regularly (painful stimuli, vital signs, eye opening, motor function/glasgow coma scale, hob elevated (~ 30 degrees, effective suctioning minimized coughing/straining, monitoring respiratory status (abgs, distress, pneumonia, ventilation, protect airway. Braden risk assessment: sensory perception, moisture, activity, mobility, nutrition, friction and shear. Client has had a seizure, has decreased loc, md advises to monitor pt, transfer to icu if not protecting his airway. Chin is up if we are protecting. Pretty much anything can happen: cause: electrical disturbance in the nerve cells, any part of the brain may be involved, 2 major categories: partial or generalized, most sudden and transient. Idiopathic or acquired: acquired trauma, high fever, seconds to minutes.
