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CONT
Persistent vegetative state: patient is devoid of cognitive function but has sleepwake cycles Akinetic mutism: unresponsiveness to the environment, the patient makes no movement or sound but sometimes opens eyes
Pneumonia
Aspiration
Pressure ulcer
Deep vein thrombosis (DVT) Contractures
Interventions
A major nursing goal is to compensate for the patient's loss of protective reflexes and to assume responsibility for total patient care; protection includes maintaining the patients dignity and privacy Maintain an airway
Frequent monitoring of respiratory status including auscultation of lung sounds Position the patient to promote accumulation of secretions and prevent obstruction of upper airway: HOB elevated 30, lateral or semiprone position Provide suctioning, oral hygiene, and CPT
CONT
Maintain fluid status
Assess fluid status by examining tissue turgor and mucosa, lab data, and I&O Administer IVs, tube feedings, and fluids via feeding tube as required: monitor ordered rate of IV fluids carefully Adjust environment and cover patient appropriately If temperature is elevated, use minimum amount of bedding, administer acetaminophen, use hypothermia blanket, give a cooling sponge bath, and allow fan to blow over patient to increase cooling Monitor temperature frequently and use measures to prevent shivering
CONT.
Brain tissues may shift through the dura and result in herniation Autoregulation: refers to the brains ability to change the diameter of blood vessels to maintain cerebral blood flow CO2 plays a role; decreased CO2 results in vasoconstriction, and increased CO2 results in vasodilatation
VS: increase in systolic blood pressure, widening of pulse pressure, and slowing of the heart rate; pulse may fluctuate rapidly from tachycardia to bradycardia and temperature increase
Cushings triad: bradycardia, hypertension, and bradypnea Projectile vomiting
Hemiplegia, decortication, decerebration, or flaccidity Respiratory pattern alterations including Cheyne-Stokes breathing and arrest Loss of brain stem reflexes: pupil, gag, corneal, and swallowing
ICP Monitoring
Diabetes insipidus
SIADH Infection
Nursing ProcessPlanning the Care of the Patient With Increased Intracranial Pressure Major goals may include:
Respirations
Fluid balance Absence of infection
Absence of complications
Interventions
Frequent monitoring of respiratory status and lung sounds and measure to maintain a patent airway Position with the head in neutral position and HOB elevation of 15 to 30 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 Treat constipation Avoid any movement that cause increase ICP (valsalva maneuver ) Monitor fluid status carefully; during acute phase, monitor I&O every hour Use strict aseptic technique for management of ICP monitoring system
Questions:
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