(^252) Medical-Surgical Nursing Demystified
to pain 2
none 1
- Motor responses obeys commands^6
localizes pain 5
withdrawal (normal) 4
abnormal flexion 3
extension 2
none 1 - Verbal responses oriented^5
confused conversation 4
inappropriate words 3
incomprehensible sounds 2
none 1 - Monitor for signs of increased intracranial pressure—diminished level of con-
sciousness, headaches, restlessness, confusion, nausea and vomiting, speech
changes, or seizures. - Notify healthcare provider of changes in neurologic status.
- Develop a means of communication with the patient—aphasia may compro-
mise use of call bell system or intercom. - Assess for neglect syndrome—patient may act as if unaware of the side
affected by paralysis due to the stroke. - Need for rehabilitation to return to prior functional ability.
- Explain to the patient:
- Home care needs.
- Proper technique to transfer from bed to chair.
- Use of ambulatory assist devices: cane, crutch, walker.
- Special dietary needs; use of Thick-it®for liquids.
- Medication schedule, use, side effects, and interactions.
Seizure Disorder
WHAT WENT WRONG?
This is a disorder that involves a sudden episode of abnormal, uncontrolled dis-
charge of the electrical activity of the neurons within the brain. The patient may
experience a variety of symptoms depending on the type of seizure and the cause.16