Cowan T (1997) Blood glucose monitoring devices. Waterlow J (1991) A policy that protects.

Thrombus formation is caused by venous stasis, decreased vasomotor tone, pressure on the blood vessels and a hypercoagulable state (Hickey 2003a). Nutritional requirements may be affected by underlying conditions that increase normal metabolic demand or require further supplements, for example, sepsis, loss of fluids and electrolytes from diarrhoea or drainage, or tissue repair following trauma ( Woodrow 2004).

Enterai feeding can prevent this by averting atrophy of the villi that absorb nutrients and produce protective mucus and immunoglobuhns. Alternatives to managing incontinence should be considered, for example, the use of a urinary sheath or incontinence pads. Moore T (2004) Suctioning. It also provides some cushioning to bony prominences. Lethargy is characterised by slow and sluggish speech, mental processes and motor activities. How do I document/word her response to verbal and tactile stimuli? Mallett J, Dougherty L (2000) The Royal Marsden Hospital Manual of Clinical Nursing Procedures. The A (airway), B (breathing), C (circulation), D (disability) approach to resuscitation should be adopted, and the maintenance of a clear airway is the first priority (Colquhoun et al 2004). A gastrostomy may be more appropriate if enterai feeding is required for longer periods, thus removing the risks associated with nasally inserted tubes. No she did not follow to command, she would grip my hands reflexively but would not let go. If someone is unresponsive, you should shout for help and dial 999. In Hickey J (Ed) The Clinical Practice of Neurological and Neurosurgical Nursing. Please consult an expert before taking any action We are excited to announce that FibromyalgiaTreating.com is now part of RedOrbit.com. A mid-sagittal view of the reticular activating system and related structures A clouding of consciousness suggests interference with the integrity of the RAS, with a resultant effect on the arousal response. 18, 7, 45-51. Woodrow P (2004) Nutrition. Therefore, care must be taken to ensure that it has been inserted correctly.

Intensive and Critical Care Nursing.

The Lancet. Therefore, regular blood and urine tests to monitor electrolyte and metabolic changes are essential to promote accurate assessment of each individual patient. Genitourinary function An unconscious patient will be incontinent of urine. Wherever there is a threat to the airway that cannot be resolved by repositioning and the clearance of secretions, the insertion of an endotracheal tube will be necessary, to protect the airway from aspiration and the associated risk of infection (Pemberton 2000).

Consciousness can be defined as a state of awareness of one’s self and the environment (Barker 2002). Cardiovascular function Monitoring the cardiovascular function in unconscious patients is of high importance. Jeanne Ballinger, RN---Join NursingCenter on Social Media to find out the latest news and special offersConnect with us on Facebook, Twitter, Linkedin, YouTube, and Pinterest. Restless. Should I just say pt not oriented to person/place/time and for LOC - stuporous? In Moore T, Woodrow P (Eds) High Dependency Nursing Care: Observation, Intervention and Support. A nursing note typically carries a patient’s basic and general information which may include information on the patient’s appearance, along with his/her past and current medical condition. If someone becomes unresponsive they need someone to help keep them safe and prevent further harm. Signals from specific parts of the thalamus initiate activity in specific parts of the cerebral cortex, as opposed to the diffuse flow of impulses from the mesencephalon that causes generalised cerebral activity (Pemberton 2000).

Communicating with relatives can aid and enhance the nurse-patient relationship by fostering understanding and empathy. Effects of prolonged immobility The morbidity of immobility is directly associated with the length of time the patient is immobile and other underlying patient risk factors (Hickey 2003a), such as incontinence, poor nutrition, hypotension, infection, obesity, old age and organ failure (Wunderlich 2002a, Hickey 2003a). In that case I would chart, "unable to assess orientation to place, time, or situation due to patient not verbally responding to questions regarding same." However, it is important that the benefits of these interventions are considered against the associated risks of compromised skin integrity and poor fluid monitoring. Stat head CT. "Sir, South Carolina, sir." Did she grasp to command and then follow command when asked to let go?

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