Many chemotherapy drugs can cause damage to the peripheral nerves of the hands and feet. Retrieved from http://www.clinicalkey.com, Cecil, R. L., Goldman, L., & Schafer, A. I. Encourage the patient to inform the ophthalmologist if there is any worsening of symptoms. Early detection of mental status alterations encourages proactive changes to the care regimen. clear airway and demonstrates appropriate breath sounds, 3) Attains/maintains environment is needed. ALOC can be caused by a head injury, medicines, alcohol or drugs, dehydration, or some diseases, such as diabetes. device periodically for urinary retention (OFarrell et al., 2001). 1. To reduce the amount of stimuli thereby preventing possible episodes of convulsion which are common in pediatric patients with meningitis. Examine the home environment for any hazards. of fecal im-paction. Pharmacologic interventions. Therefore, identify the relevant term, or make appropriate language translations. Her experience spans almost 30 years in nursing, starting as an LVN in 1993. The term, MONITORING AND MANAGING A technique such as a hand clap can be used to break up the unpleasant idea. Altered mental status (AMS) is a general term used to describe various disorders of mental functioning ranging from slight confusion to coma. Terms and Conditions, surroundings but still cannot react or communicate in an ap-propriate fashion. Nursing Diagnosis: Disturbed Sensory Perception (Auditory) related to damage in the inner ear secondary to Menieres disease as evidenced by recurrent vertigo, tinnitus or ringing in the ears, verbal complaint of hearing and communication problems. Appropriate skin care is implemented to prevent these complications. Rapid diagnosis is key in seniors who present to the emergency department (ED) with altered mental status, as the cause may be a life-threatening condition. She has worked in Medical-Surgical, Telemetry, ICU and the ER. Encourage the patient to use visual aids. We and our partners use data for Personalised ads and content, ad and content measurement, audience insights and product development. The risk of injury can be lowered if the patient employs appropriate aids to promote visual and auditory orientation to the surroundings. Nursing Diagnosis: Disturbed Sensory Perception related to cerebral edema and increased intracranial pressure secondary to meningitis as evidenced by lack of orientation to time, person, and place and decreased level of consciousness. track marks) MANAGEMENT The initial management of patients with an altered LOC involves stabilizing ABCs, protecting the patient from further injury (e.g. She takes the topics that the students are learning and expands on them to try to help with their understanding of the nursing process and help nursing students pass the NCLEX exams. Determine the patients age, growth level, overall health, lifestyle, impaired communication, intellectual disabilities, movement, conceptual understanding, and decision-making abilities. Dementia is a slow, progressive loss of mental capacity, leading to deterioration of cognitive abilities and behavior. References. In Brunner and Suddarths textbook of medical-surgical nursing (11th ed., pp. You will need to stay in the hospital for testing and treatment because you experienced ALOC. Chest physiotherapy and suctioning are initiated to prevent All episodes of ALOC require careful observation, especially in the first 24 hours. Retinopathy and peripheral neuropathy are some of the complications of diabetes. [9][10], Differential Diagnosis for Altered Mental Status. condition, permit the family to be involved in care, and listen to and Manage Settings When around the urethral orifice is in-spected for drainage. Advise the patient to have regular checkups or appointments with a primary care provider, mainly if some mental disturbances are observed. Blood tests to check your blood sugar level and oxygen level, or for dehydration, infections, drugs, or alcohol, Blood, urine, or other tests to monitor how well your organs are functioning. It is critical to get enough sleep, eat healthily, and engage in regular physical activity. In very severe cases, you may need a tube put into your lungs to help you breathe. If acute sedation is needed, consider haloperidol (5 mg to 10 mg by mouth, intramuscularly, or intravenously, butconsider reduced dosing in the elderly). GCS is a universal method of assessing the level of consciousness, which includes the measurement of the persons sensory, verbal, and motor cues. Assess vital signs and perform an initial head-to-toe assessment, particularly checking visual acuity, presence of tingling or numbness in the extremities, and response to pain stimuli. When eliciting a history from a patient who presents for altered mental status, it is important to obtain information both from the patient and from collateral sources (e.g., parents, children, friends, emergency management services, bystanders, the patients primary physician). Rakel, R. E., & Rakel, D. (2011). POTENTIAL COMPLICATIONS, Vital signs and respiratory function are monitored closely to detect any signs of respiratory failure or distress. related to mouth-breathing, absence of pharyngeal reflex, and altered fluid They may require additional time to formulate thoughts. decreased level of consciousness (LOC) The nurse is caring for a client immediately after supratentorial intracranial surgery. Where to begin assessing the patient with an altered LOC de-pends somewhat on each patients circumstances, but clinicians often start by assessing the verbal response. Put the call light within reach and teach how to call for assistance. Coma, which looks as if you are asleep, but you cant be awakened at all. Study Material, Lecturing Notes, Assignment, Reference, Wiki description explanation, brief detail, Medical Surgical Nursing: Management of Patients With Neurologic Dysfunction : Nursing Process: The Patient With an Altered Level of Consciousness |, Nursing Process: The Patient With an Altered Level of Consciousness. Vascular dementia is similar to Alzheimer disease, although patients may have signs of motor abnormalities in addition to cognitive changes, and may exhibit a fluctuating step-wise decline, as multiple vascular events have an additive effect on the patients function[1][4][3]. [1] Given the vagueness of the term, it is imperative to understand its key components before considering a differential diagnosis. healthy oral mucous membranes, 7) Attains Stupor and coma are rated according to how severe the symptoms are. the family may require considerable time, assistance, and support to come to The nurse should then complete a nursing care plan based on the diagnosis. by limiting background noises, having only one person speak to the patient at a Stressful life events such as Financial struggles, the death in the family or loved ones, or divorce, Brain damage caused by a catastrophic accident, such as a forceful, Few friends or a small number of healthy relationships, Excessive intake of alcoholic beverages or recreational substances. View your health information including your medications, test results, scheduled appointments, medical bills even if you have multiple doctors in different locations. Allow enough time for the patient to reply. Anna Curran. To help family members mobilize their adaptive Patients rarely have a rapid fluctuation of symptoms and are usually oriented and able to follow commands [1][4][3]. Developed by Therithal info, Chennai. Bisnaire et al., 2001). depending on the patients condition, to promote a normal body temperature. It is critical to assess the patients psychological condition to identify relevant elements. Check the patient's skin, gums, stools, and vomitus for bleeding. Keep an eye out for warning signals. community organizations. F A Davis Company. alive, with the heart rate and blood pressure sustained by vaso-active This helps reduce the fluid buildup in the affected ear. . While Altered mental status is generally associated with psychological and emotional disorders, physical ailments and traumas that induce brain damage, such as alcohol or drug intoxication and withdrawal syndromes, can also trigger mental stability disturbances. We and our partners use cookies to Store and/or access information on a device. 117006721_Risk_for_Infection_Pneumonia_Nursing_Care_Plan.docx. maintenance of a patent airway A client is exhibiting signs of increasing intracranial pressure (ICP). The nurse can monitor the vital signs and assess for an underlying cause through a thorough physical examination and history assessment. NURSING PROCESS: THE PATIENT WITH AN ALTERED LEVEL OF CONSCIOUSNESS Assessment Where to begin assessing the patient with an altered LOC de-pends somewhat on each patient's circumstances, but clinicians often start by assessing the verbal response. She is a clinical instructor for LVN and BSN students and a Emergency Room RN / Critical Care Transport Nurse. In infants and children, the most common causes of altered mental status include infection, trauma, metabolic changes, and toxic ingestion. The term brain death describes irreversible loss of all functions of the nursing! dead before physiologic death occurs. Altered level of consciousness (ALOC) means that you are not as awake, alert, or able to understand or react as you are normally. 1. Contributed by Laryssa Patti, MD. occur with fecal impaction. To monitor if the hearing loss is worsening and if there is a need for further investigation and change of hearing aid. St. Louis, MO: Elsevier. Copyright 2018-2023 BrainKart.com; All Rights Reserved. Some of our partners may process your data as a part of their legitimate business interest without asking for consent. If there are signs of impending herniation (e.g., Cushing reflex or a unilateral blown pupil), elevate the head of the bed to 30 degrees, increase the respiratory rate, and consider mannitol and neurosurgical decompression. Vital signs and respiratory function are monitored closely to detect any signs of respiratory failure or distress. healthy oral mucous membranes, Receives Blood tests performed to assess the health of the liver, kidneys, and. Prophylaxis such as sub-cutaneous heparin Sunglasses can help protect the eyes from the danger of ultraviolet rays. Desired Outcome: The patient will be able to cope with the auditory loss as evidenced by improved communication and quality of life. An altered level of consciousness is characterized as a decreased wakefulness, awareness, or alertness, and includes a range of categories like hyperalert, delirious, lethargic, and comatose. (Hauber & Testani-Dufour, 2000). terms with these changes. Validation informs the patient that the nurse has heard and comprehended the facts and concerns expressed. inserted. Unless the patient has a hearing impairment, avoid speaking loudly. The patient may require an enema every other day to empty the lower integrity related to immobility, Impaired tissue integrity of family because although brain function has ceased, the patient appears to be Anna Curran. videotaped fam-ily or social events may assist the patient in recognizing Advise to wear sunglasses when out and about. no clinical signs or symptoms of dehydration, Demonstrates Recommend to relevant resources such as a speech pathologist, group therapy, supportive psychotherapy, and psychiatric counseling. The following are the therapeutic nursing interventions for patients at risk for injury: 1. Explain when the assessment of the Glasgow coma score should be done in conjunction with a mental status exam. CT Scan used to capture photographs of the head. http://creativecommons.org/licenses/by-nc-nd/4.0/ (2020). Doenges, M. E., Moorhouse, M. F., & Murr, A. C. (2019).
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