Collaborative Problems in Altered Level of Consciousness and Stroke Management

Collaborative Problems and Complications of Altered Mental Status

• Overview of Altered Mental Status (AMS) and Level of Consciousness (ALC)     - Patients with an altered level of consciousness always have an underlying cause that must be addressed.     - Potential causes include:         - Sedation.         - Seizures.         - Stroke symptoms.         - Trauma (e.g., car accidents, falls).         - Spinal cord injury.     - Note for students: Advanced topics like intracranial pressure (ICP) and complex brain injury mechanics are typically covered in the fourth semester.
• Major Respiratory Complications     - Respiratory Distress: Occurs if the patient is unable to maintain their own airway due to their altered state.     - Pneumonia: Frequency increases due to mechanical ventilation or the inability to take deep breaths and clear secretions.     - Aspiration: Particularly common in stroke patients due to an inability to swallow correctly.         - The epiglottis may not function properly, leading to the inhalation of liquids or secretions.         - Patients can aspirate even on very small amounts of fluids.
• Mobility-Related Complications     - Pressure Ulcers: Patients with ALC cannot move themselves, requiring nurses to perform frequent positioning and skin assessments.     - Deep Vein Thrombosis (DVT): A significant risk factor due to prolonged lack of mobility.     - Contractures:         - In reality (contrary to movie depictions), muscles and ligaments tense and pull extremities inward when they are not used.         - If the body does not move, the muscles contract and ligaments become permanentely shortened.
• Essential Nursing Goals for ALC Patients     - Maintaining body fluid balance through strict monitoring of intake and output ($I\&O$).     - Maintenance of skin integrity.     - Preventing Corneal Irritation: Patients may lose the ability to close their eyes. Intervention includes eye patches or using tape to keep eyes closed.     - Effective Thermoregulation: Brain damage or trauma can disrupt the hypothalamus, which acts as the body's thermostat.         - Patients may become excessively hot or cold.     - Accurate Perception of Environmental Stimuli: Patients often become disoriented; nurses must try to establish a daytime and nighttime routine.     - Maintaining Family and Support Systems: It is vital to identify the primary support person (spouse, child, partner) and involve them in the care process, especially for previously productive individuals who have lost independence.

Maintaining Physiological Function in the Altered Patient

• Airway and Respiratory Management     - Frequent monitoring of respiratory status and lung sounds to detect pneumonia early.     - Prevention of Obstruction: Implement measures to promote the accumulation and removal of secretions.         - Positioning: Head of the bed at $30^{\circ}$.         - Lateral or semi-prone positioning.         - Chest physiotherapy.     - Oral Hygiene: Essential to prevent bacteria in the mouth from spreading to the lungs and causing pneumonia.
• Tissue Integrity and Alignment     - Frequent skin assessment over bony prominences.     - Turning Schedules: Patients should be turned at least every hour; some may require specialized air mattress beds that rotate automatically.     - Positioning Tools:         - Splints to prevent contractures.         - Trochanter rolls to assist with hip alignment.         - Foam boots, silicone wedges, and specialty beds.
• Passive Range of Motion (PROM)     - Essential for patients where the brain is not sending signals to the muscles or when movement is impossible.     - Nurses should rotate limbs and move wrists to prevent the hand from contracting into a permanent fist.     - Rolled-up towels can be placed in hands to maintain functional alignment.
• Eye and Oral Care Details     - For patients whose eyes remain open: Use moistened saline, gauze, or washcloths to clean the eyes.     - Application of artificial tears.     - Protection using eye patches to prevent corneal scratches.     - "Scrupulous oral care" to minimize bacterial load.
• Fluid and Nutrition Status     - Replacement Strategies: IV fluids or tube feedings.     - Feeding Tubes: Dobhoff, Gastrostomy tubes (G-tubes), or Jejunostomy tubes (J-tubes) for long-term needs.     - Total Parenteral Nutrition (TPN): Used if the patient has a central line and cannot tolerate enteral feeding.     - Nutrition is the "building block" required for the body to heal from the underlying cause of ALC.
• Thermoregulation Interventions     - Hypothermia (Low Temp): Use Bear Huggers or additional blankets.     - Hyperthermia (High Temp): Use minimum bedding, fans, cooling blankets (hypothermia blankets), and cooling sponge baths.     - Pharmacology Note: Tylenol (Acetaminophen) may be ineffective if the fever is caused by hypothalamus dysregulation.     - Avoiding Shivering: Shivering is a metabolic demand that uses excessive energy the sick patient cannot afford to expend.
• Bowel and Bladder Management     - Monitor for urinary retention vs. incontinence.     - Catheterization: Intermittent catheterization is preferred over indwelling Foley catheters to reduce the risk of infection (avoiding the "nice little road" for bacteria to enter the bladder).     - Bowel Care: Monitor for abdominal distension and constipation.         - Intervention if no bowel movement occurs in $3\,\text{days}$.         - Use of stool softeners, glycerin suppositories, or enemas.         - Note: Diarrhea may result from hyperosmolar tube feedings or antibiotic use.

Sensory, Psychosocial, and Communication Needs

• Interaction with Altered Patients     - Professional ethics: Avoid talking about the patient as if they are not there.     - Research indicates hearing is one of the last senses lost; patients often report hearing conversations while in a coma.     - Include the patient in conversations.
• The Importance of Touch     - Use therapeutic touch (even with gloves) to provide a sense of connection.     - Reference to Reiki or "energy" when family or staff touch the patient.
• Circadian Rhythm Support     - Establish a normal daylight pattern: Open blinds and turn on lights in the morning; close blinds and dim lights in the evening.     - This helps prevent delirium (a temporary state of confusion distinct from dementia).
• Recovery and Agitation     - As patients arouse from a coma, they may experience agitation or confusion similar to emergence from anesthesia ("coming out swinging").     - The nurse should remain calm and repeatedly tell the patient they are safe.
• Family Support     - Allow family to "ventilate" (vent) frustrations.     - Provide consistent information regarding the plan of care and doctor visit timings.     - Refer families to specific support groups related to the patient's condition.

Seizure Management and Nursing Care

• Diagnosis and Monitoring     - Seizures are monitored via EEG (electroencephalogram).     - Special units (like those at Banner) perform continuous EEG readings to locate seizure activity in the brain for potential ablation surgery.
• Nursing Actions During a Seizure     - Observe and Document: Note signs before, during, and after the seizure.     - Aura Identification: Ask the patient if they experienced a trigger (e.g., bright lights, smells, or a specific feeling called an aura).     - Safety (Priority):         - Gently guide the patient to the floor if they are standing or walking.         - Do NOT restrain the patient.         - Do NOT pry the jaw open or place anything in the mouth (risk of broken teeth, jaw injury, or choking on material like bite blocks).         - Position the patient in a side-lying (fetal) position to clear secretions and prevent aspiration.         - Provide supplemental oxygen if available.         - Pad side rails or the floor if possible.
• Duration and Severity     - Standard seizures: $30\,\text{seconds}$ to $1\,\text{minute}$.     - Status Epilepticus: A seizure lasting more than $5\,\text{minutes}$. This is a medical emergency described as a "computer glitch" that can "fry" the brain if not stopped.
• Postictal Stage (After the Seizure)     - Maintain a patent airway in a side-lying position.     - Reorient the patient as they will likely be confused or have a lapse in time.
• Pharmacological Management of Seizures     - Adherence can provide $70-80\%$ control of seizures.     - Common Medications:         - Short-term/Acute (to stop a seizure): Lorazepam (Ativan) IV or IM; Clonazepam.         - Maintenance/Maintenance-like Drugs: Carbamazepine, Phenobarbital, Phenytoin (Dilantin), Topiramate (Topamax), Levetiracetam (Keppra).         - Neuropathic/CNS threshold: Gabapentin.         - Antipsychotic/Seizure use: Lamotrigine (Seroquel).     - Side Effects: Drowsiness and potential liver toxicity (requires monitoring).

Stroke (Cerebral Vascular Accident or "Brain Attack")

• Definition: Brain cells die due to oxygen deprivation caused by blocked flow or damaged vessels.
• Two Primary Types of Stroke:     - Ischemic Stroke ($80-85\%$ of cases): Blood flow is blocked.         - Thrombotic: Obstructed by arteriosclerosis in the brain.         - Thromboembolic: A clot breaks off an atherosclerotic plaque elsewhere and lodges in the brain.         - Embolic: Clot travels from elsewhere (common in Atrial Fibrillation or post-MI due to irregular blood flow).     - Hemorrhagic Stroke: A blood vessel bursts due to high blood pressure, atherosclerosis, or congenital malformation.         - Causes bleeding into the brain and increased intracranial pressure (ICP).
• Transient Ischemic Attack (TIA): A temporary precursor where symptoms resolve before cell death occurs.
• Stroke Assessment: BE FAST     - B - Balance.     - E - Eyes (peripheral loss, focus issues).     - F - Face (facial droop).     - A - Arm (arm drift, usually unilateral).     - S - Speech (slurred or articulate problems).     - T - Time (the most important part of the assessment to determine treatment eligibility).
• Primary and Secondary Prevention     - Lifestyle Changes: Smoking cessation, increasing physical activity (walking $3\,\text{times/week}$), weight maintenance.     - Diet: DASH diet (high fruit/veg, low animal protein) or Mediterranean diet (avocados, nuts).     - Medical Management:         - Treatment of hypertension (priority risk factor).         - Carotid endarterectomy (for stenosis).         - Anticoagulant therapy for Atrial Fibrillation.         - Antiplatelet therapy: Aspirin (low dose), Clopidogrel (Plavix), Eliquis, or Xarelto.         - Statins to reduce cholesterol plaques.

Acute Management of Stroke

• Ischemic Stroke Treatment     - Thrombolytic Therapy (tPA): Known as a "clot buster."         - Window: Must be given within $3$ to $4.5\,\text{hours}$ of the onset of symptoms.         - Door-to-Needle Goal: Administration within $45\,\text{minutes}$ of arrival at the ED.         - Criteria: Patient must be over $18$; not for minor TIAs; check PT/INR; no history of prior brain hemorrhage or AV malformations.     - Nursing Monitoring: Watch for potential bleeding (opposite effect) and conduct frequent neuro assessments (NIH Stroke Scale).
• NIH Stroke Scale (NIHSS):     - A focused, intense assessment measuring level of consciousness, gaze, visual acuity, and motor function.     - Includes cognitive tests: naming objects (e.g., a bicycle) or reading specific sentences.
• Hemorrhagic Stroke Treatment     - Distinguishing Symptom: Sudden onset of the "worst headache of their life."     - Diagnosis: CT scan (priority), angiography, or lumbar puncture (if CT is negative).     - Acute Care: Bed rest with sedation to prevent ICP elevation; maintain specific blood pressure parameters (not too high to cause more bleeding, not too low to tank perfusion).

Rehabilitation and Nursing Responsibilities

• Physical Rehabilitation     - Shoulder Health: $84\%$ of stroke patients have shoulder issues on the affected side; use slings and support.     - Mobility: Use assistive devices (grabbers for socks) and encourage independence.     - Family Role: Prevent family from doing everything for the patient, which might decrease the patient's incentive to recover.
• Swallow and Nutrition     - Evaluation: Perform a small swallow eval (usually with a medicine cup of water at a $90^{\circ}$ angle) within $4$ to $24\,\text{hours}$.     - Patients are NPO (nothing by mouth) until a formal speech therapy swallow evaluation is completed.
• Communication Strategies     - Patiently allow the patient to finish their own sentences.     - Speak slowly and look them in the eye.
• Pseudo-bulbar Affect: A phenomenon where brain damage causes inappropriate emotional reactions (e.g., laughing when receiving sad news).

Questions & Discussion

• Q: Why don't we put anything in the mouth during a seizure?     - A: The patient's strength is unmeasurable; they can break objects and choke on the material, or break their own teeth.
• Q: If a patient has high blood pressure during a stroke, does that mean they weren't adhering to their meds?     - A: Not necessarily. When the body detects a blockage in the brain, it naturally spikes the blood pressure to try to force blood through to perfuse the area.
• Case Study Review (68 y/o Male)     - Scenario: Hx of HTN, DM2, hyperlipidemia. Right-sided weakness, unknown onset time. BP $190/110\,\text{mmHg}$. CT shows left MCA ischemic stroke.     - Medication Adherence: The most important education point to prevent recurring strokes in this specific patient.     - Intervention Priority: Perform a neurological assessment to establish a baseline.     - Acute Risk: Deep Vein Thrombosis (DVT) due to right-sided immobility.     - Rehab Goal: Return to independent living (highest functional state possible).