Level 3 Exam 2: Grief, EOL, Human Dev, ICR

stages of grief

denial, anger, bargaining, depression, acceptance

meningitis lumbar puncture

determines whether meningitis is present and whether it is bacterial or viral

subarachnoid screw or bolt

device placed into the subarachnoid space to measure intracranial pressure

treats epilepticus, anxiety and muscle spasms

diazepam

flaccidity

displaying lack of muscle tone; limp, floppy

If drainage occurs

do not clean or suction from ears or nose

Bromocriptine

dopamine agonist treats Parkinson's often in combo with levodopa

bacterial meningitis precautions

droplet precautions, stay 3 feet away

down syndrome

early intervention and come to appts

development delay

early intervention is key -important to meet milestones

Which speech pattern is observed in autistic children?

echolalia

papilledema

edema and hyperemia (increased blood flow) of the optic disc always a sign of increased ICP

seizure diagnostic test

eeg, ct, mri, spect/pet

a fib at risk for

embolic

status epilepticus

episode in which the pt experiences multiple seizure bursts with no recovery time in between

hospice eligibility

expected death within 6 months -no aggressive disease mgmt -dnr

pt teaching tonic-clonic seizure

explain strategies a client may use to prevent physical trauma from occurring during a seizure

ptosis

eyelid drooping

complicated grief

failure to process through grief process

infant with infected ventriculoperitoneal shunt with possible meningitis

fever lethargy stiff neck poor feeding

greatest risk for shunts for hydrocephalus

fever accompanied by decreased responsiveness is associated with infection

meningitis assessment

fever, chills, h/a vomiting, diarrhea anorexia nuchal rigidity poor or high, shrill cry altered loc, such as lethargy or irritability bulging anterior fontaneal in an infant positive Kernig's sign and Brudzinski's sign -muscle or joint pain -petechial or purpuric rashes -ear that chronically drains

valproic acid

first line treatment for absence seizures

cerebral compression

fixed, dilated right pupil responds only to painful stimuli exhibits flexion (decorticate) posturing

Down syndrome looks like

flat occiput broad nose with depressed bridge (saddle nose) small, misshapen, low-set ears keep mouths open, tongues protruding surface of tongue is often wrinkled inner epicanthic folds transverse palmar crease hypotonia

Toddler with autism behaviors

flat, blank facial expression laughing when pulse is taken inability to maintain eye contact

3 types of seizures

focal-one part of brain and may/may not alter LOC generalized-occur over entire brain and do alter LOC unknown-can be focal or generalized; epileptic and infantile spasms are examples

palliative care

focuses on quality of life can still opt for life-extending or curative tx

basilar skull fracture

fracture of the base of the skull; symptoms are battle sign, racoon eyes, rhinorrhea, otorrhea and hemotympanum (blood behind the eardrum)

comminuted skull fracture

fragmentation of the bone into many pieces or a multiple fracture line

epilepsy

group of syndromes characterized by paroxysmal transient disturbances of brain function

vital meningitis s/s

h/a fever photophobia

meningitis s/s adolescents

h/a photophobia nuchal rigidity fever altered loc decreased appetite vomitting diarrhea drowsiness agitation

cerebral aneurysm assessment

h/a, pain irritability visual changes tinnitus hemiparesis nuchal rigidiy seizures

sign of hemorrhagic stroke

headache

what is oral contraceptive associated with?

hemorrhagic

hormone replacement therapy

high risk of breast cancer, blood clots and stroke

stroke highest risk factor

hypertension -obesity, substance abuse disorder, diabetes, red meat

vertigo

illusion of movement in which the individual or the surroundings are sensed as moving

ADHD behavior

impulsiveness excessive talking playing video games for hours on end failure to follow through/finish tasks

ataxia

inability to coordinate muscle movements, resulting in difficulty in walking, talking and performing self-care activities

hydrocephalus assessment

inability to move eyes laterally may indicate dev, as well as increased ICP and urinary incontinence

rigidity

increase in muscle tone at rest characterized by increased resistance to passive stretch

meningitis lab findings

increased pressure >1000 wbc >500 protein decreased glucose cloudy appearance

which csf finding shows bacterial meningitis

increased protein level

head injury

injury to the scalp, skull and/or brain

common responses with loss

insomnia depressed mood anxiety anorexia

brain death

irreversible loss of all functions of the entire brain, including the brain stem

2 types of strokes

ischemic: thrombotic & embolic (blockage) hemorrhagic: aneurysm, arteriovenous malformation, hypertension

Which behavior would be typical for a child with autism?

lack of eye contact

Which characteristic is commonly seen in children who have autism?

lacks response to environment

furosemide

lasix, loop diuretic -adjuntive therapy to decrease incidence of rebound from mannitol -enhances therapeutic action of mannitol -decreases sodium uptake by the brain -decreases CSF production at choroid plexus

tonic clonic seizures

lasts 2-5 minutes begins with tonic phase that causes stiffening or rigidity of muscles and loss of consciousness

clonic seizures

lasts several minutes and causes muscle contraction and relaxation

client has had a stroke

lopsided smile unilateral vision incoherent speech unable to raise right arm symptoms started 2 hours ago

anticipatory grief

loss is expected or predictable

disenfranchised grief

loss that is not a socially recognized relationship (abortion, death of pet)

What is contraindicated with increased ICP?

lumbar puncture

diagnosis of meningitis

made by testing the CSF obtained by a lumbar puncture; fluid is cloudy with increased pressure, increased WBC, elevated protein and decreased glucose levels

Parkinson's risk factors

male over 40 family hx traumatic brain injury brain tumor/other lesion mask like face freezing slow shuffling gait changes in speech

complication of otitis media

mastoiditis (inflammation of mastoid gland) hearing loss bacterial meningitis

febrile seizures

may occur in minor illnesses

meningococcal meningitis

medical emergency w/ fairly high mortality rate, often within 24 hours, highly contagious, most likely to occur in high population densities

status epilepticus

medical emergency, prolonged lasting longer than 5 minutes or repeated seizures over course of 30 min

viral meningitis

meningitis caused by a virus associated with mumps, paramyxovirus, herpesvirus and enterovirus

hydrocephalus aquired as complication from....

meningitis, tumor or hemorrhage

most common stroke

middle cerebral artery strokes (affects the most common artery hurt by CVA)

low blood sugar

mimics stroke

how do Parkinson's pt die?

mobility complications

craniotomy care

monitor neuro and vital signs q15-30 min for first 4-6 hours then every hour report head dressing for excessive amounts of drainage >50mL/8hr

interventions for seizures

monitor urinary output seizure precautions monitor liver and renal function tests and med blood serum levels

2 weeks out of death

more confused, see people

phenytoin

must be given slowly to prevent hypotension and cardiac dysrhythmias may decrease effects of birth control

bacterial (meningococcal) meningitis s/s

neck stiffness, severe h/a, decreased LOC

Absence seizures

no muscle activity occurs except rolling of eyes blank facial expression 5-20 seconds

Parkinson's diagnostic tests

no specific tests DaT MRI analysis of CSF -monitor swallowing/eating

atomoxetine hydrocholoride (strattera)

non stimulant monitor for suicidal ideation adhd

seizure nursing interventions

nothing in mouth turn pt to side suction oral secretions if possible loosen clothing record time

first action in seizure

obtain a hx of seizure type and incidence

brain injury, open

occurs when an object penetrates the skull, enters the brain, and damages the soft brain tissue in its path (penetrating injury), or when blunt trauma to the head is so severe that it opens the scalp, skull, and dura to expose the brain

brain injury, closed (blunt)

occurs when the head accelerates and then rapidly decelerates or collides with another object and brain tissue is damaged, but there is no opening through the skull and dura

general seizures

onset at any age LOC is impaired

methadone

opioid

seizure precautions

padded rails low bed nothing in mouth side lateral position loosen clothes around neck stay with child reocrd time

EOL symptoms that cause distress

pain weakness breathlessness/dyspnea n/v agitation and delirum seizures

kernig sign

pain with extension of leg and knee sign of meningitis

evaluate effectiveness of shunt

palpating the anterior fontanel

seizures

paroxysmal transient disturbance of the brain resulting from a discharge of abnormal electrical

fentanyl

patch is absorbed by fat, not a lot of fat at EOL

Cheyne-Stokes respiration

pattern of breathing characterized by a gradual increase of depth and sometimes rate to a maximum level, followed by a decrease, resulting in apnea

antibiotics

penicillin ampicillin cephalosporin -allergy to one, allergy to all -take with food if GI upset -safe for pregnancy -less effective oral contraceptive

infant during postop period after shunt is placed

place infant flat with head on unaffected side

most important intervention for 2yo seizure

placing child in side lying position

meningitis s/s infant

poor feeding vomiting irritability seizures high pitched cry bulging anterior frontanel lethargy

sign of meningitis

positive Kernig sign (severe stiffness of hamstrings causes an inability to straighten the leg when the hip is flexed to 90 degrees)

most common reason for development of status epilepticus

prescribed antiseizure med probably is not taken consistently

intracranial pressure (ICP)

pressure exerted by the volume of the intracranal contents within the cranial vault

brain tumor

primary can be genetic risk factor-pituitary dysfunction

coma

prolonged state of unconsciousness

priority action when preparing to provide grief counseling

provide an environment for client to express feelings

late hydrocephalus

setting sun sign front bone enlargement vomiting diffuculty feeding/swallowing increased bp decreased hr SHRILL, high pitched cry sluggish or unequal pupillary response to light

shunts for hydrocephalus

shunts are updated with the length of the tubing increased as the child grows

stroke risk factor

sleep apnea rehab monitor lipids stress obesity risk factors

stroke on left side of brain

slow performance and caution impaired speech/languge aphasias awareness of deficits with depression and anxiety

festinating gait

small rapid steps resulting from a forward-tilted head and trunk posture -related to Parkinsons

docusate sodium

start with this to treat constipation -stool softener, laxative

minimally conscious state

state in which the pt demonstrates awareness but cannot communicate thoughts or feelings

anti-cholesterol

statins

Parkinson's surgery

sterotactic pallidotomy (opening into the palladium within the corpus striatum) -deep brain stimulating DBS

dextroamphetamine sulfate (dexedrine)

stimulant, give in morning

Methylphenidate hydrocholoride (ritalin)

stimulant, give in morning first choice of med for adhd

megestrol

stimulates appetite and increases weight

dextroamphetamine/ampethamine (adderall)

stiumlant, give in morning

linear skull fracture

straight line fracture, dura not involved

leading cause of seizure in elderly

stroke

status epilepticus causes

sudden withdrawal from antiepileptic drugs -infection -acute alcohol or drug withdrawal -head trauma -cerebral edema -metabolic disturbances

newborn position after insertion of ventriculoperitoneal shunt for hydrocephalus

supine on unaffected side

ventriculoperitoneal shunt

surgery to treat CSF from the brain to treat hydrocephalus

transsphenoidal

surgical approach to the pituitary via the sphenoid sinuses

craniotomy

surgical procedure that involves entry into the cranial vault

VNS

surgically implanted in left chest wall, pt can active VN -observe for complications after procedure such as hoarseness, cough, dyspnea, neck pain or dysphagia -teach pt to avoid MRIs, microwaves, shortwave radios, and ultrasound diathermy (PT heat treatment)

spasticity

sustained increase in tension of a muscle when it is passively lengthened or stretched

Who can detect adhd/add?

teachers

TIA explanation

temporary episodes of neurological dysfunction; narrowing of arteries supplying the brain causes temporary neurological deficits that last for a short period

concussion

temporary loss of neurologic function with no apparent structural damage to the brain

ICP sign in infant

tense/bulging anterior fontanel

Romberg test

test for cerebellar dysfunction that can be done with the pt seated or standing; inability to maintain position for 20 sec is a positive test

acute grief

the intense physical and emotional expression of grief occurring as the awareness increases of a loss of someone or something significant

The signs of autism are initially evident at which age?

2 years

progesterone

A hormone produced by the ovaries which acts with estrogen to bring about the menstral cycle. -often combined with estrogen

Monro-Kellie hypothesis

theory that states that due to limited space for expansion within the skull, an increase in any one of the cranial contents-brain tissue, blood or cerebrospinal fluid--causes a change in the volume of the others; also referred to as Monro-Kellie doctrine

hydrocephalus parent edu

there is a part of the brain surface that usually absorbs spinal fluid after its production that is not functioning adequately

plantar flexion

tip toes

tonic-clonic seizure

tonic: stiffening of muscles clonic: symmetric and rhythmic, contraction and relaxation, less than 5 min tonic-clonic: followed by a variable period of lethargy, confusion and sleep (postical phase)

heparin

too slow for stroke symptoms -anticoagulant -ptt: 46-70? -fast acting

meningitis interventions

provide resp isolation and maintain for 24 hours admin antibiotics and antipyretics neuro assessment monitor is and os pneumoccoal conjugate vaccine is recommmended for all children beginning at 2 months to protect against meningitis; stretococcal pneumococci can cause many bacterial infections, including meningitis

hospice care

provider certifies 6 months or less to live goal is to humanize EOL can't opt for life extending or curative treatment

meningitis risk

pt with infection in head or neck/throat immunosuppressant

brain attack

pulse drops bp increases

What to watch after craniotomy?

pupils

infant with meningococcal meningitis

purpuric skin rash

early hydrocephalus

rapid head growth full, bulging anterior fontanel irritability poor feeding distended, prominent scalp veins widely separated cranial sutures

concussion

transient and reversible neuronal dysfunction with instaneous loss of awareness and responsiveness

CVA risk factors

transient ischemic attacks (TIAs)

diazepam

treat status epilepticus

ALS interventions

treat symptoms monitor resp

haloperidol

treats agitation

albuterol

treats dyspnea

estrogen (estradiol)

treats menopausal symptoms -risk for clots, gallbladder disease -w/o progestin, increased risk for endometrial cancer -avoid grapefruit -monitor vision -over age 65 risk for dementia - do not place patch on breast or waistline -metabolized in liver

S/s of child with autism spectrum

repetitive activities inability to adapt to change lack of comm

ALS Assessment

resp difficulty fatigue while talking muscle weakness/atrophy tongue atrophy dysphagia weakness of hands/arms fascicultations of the face nasal quality of speech dysarthria

scopolamine patch

treats n/v

Parkinson's look like

resting tremors masklike face rigidity to passive movement flattened affect

earliest indicator of increased icp

restlessness

levodopa

restores dopamine levels in the brain

meningitis

result from neurosurgery, trauma, infection of sinuses or ears or systemic infections

meningitis

result of complication of neurosurgery, trauma, systemic infection or sinus or ear infection

tonic-clonic seizures

rhythmic body jerking

Which play activity is the best choice to suggest to the parents of a school aged child with autism?

riding on a playground merry go round

Parkinson's mgmt

safety

increased ICP on 2yo with meningitis

seizures vomiting decreased resp rate

photophobia

sensitivity to light

depressed skull fracture

bone pressing downward, indented

seizures

brief paroxysmal behavior caused by excessive abnormal discharge of neurons

observation during seizure

-changes in pupil size/eye deviation -loc -apnea, cyanosis, salivation -incontinence of bowel/bladder -eye fluttering/blinking -lip smacking -tongue/biting lip

benzodiazepines

-clonazepam, clorazepate, diazepam, lorazepam -treat absence seizures

meningitis s/s

-decreased LOC, disorientation to person, place and time -pupil reaction and eye movement -photophobia -nystagmus -hemiparesis, hemiplegia and decreased muscle tone possibly later -memory changes: attention span, personality and behavior changes, severe unrelenting headaches, myalgia, n/v, fever and chills, tachycardia, red muscular rash

streptokinase

-indicated for ischemic stroke -3-4.5 hours from onset of symptoms -monitor for bleeding, no injections at all contraindication: do not admin in central line, must be in a compressible site like a periperal IV; not w/ active bleeding; HTN >180/110; recent surgeries

stroke causes

-thrombosis -embolism -thrombotic and embolic: ischemic -hemorrhagic

mannitol

-treats cerebral edema -want to see changes in neuro vital signs 30 min-1 hour after admin -most effective when giving bolus rather than continuous infusion -does not improve mortality, just decreases ICP -monitor pts taking with loop diuretics for Is and Os

meningitis nursing intervention

-vitals and neuro check -perform cranial nerve assessment -manage pain -intake and output -dw -rom exercises q4 -decrease env stimuli -hob elevated 30 degrees

contusion

bruising of the brain surface

max amount of time pt with cva remain in one position

1-2 hours

5 stages of grief

1. Denial 2. Anger 3. Bargaining 4. Depression 5. Acceptance

normal ICP

10-15 MM Hg >20 detrimental-causes brain to die

avg newborn head size

12.6-14.5 inches

hydrocephalus s/s

bulging fontanels high pitched crying defect in lumbosacral area

meningitis

can be mistaken for encephalitis (infection of brain tissue and surrounding meninges)

stroke causes

carotid stenosis-hardening/narrowing of artery

mild concussion follow up

check for changes in responsiveness every 2 hours for 2 days

meningococcal meningitis isolation

24-72 hours after initiation of antibiotic therapy

time of death

check on family call funeral home post mortar care

what respirations in stroke?

cheyen-stokes (apnea and hyperventilation)

Cushing's triad

3 classic signs: bradycardia, hypertension, and bradypnea--seen with pressure on the medulla as a result of brain stem herniation

active death

3 days inability to arouse patients -longer periods of apnea -dramatic changes in breathing -breathing through mouth -incontinence -decrease in urine, dark -bp drop dramatically -systolic below 70, diastolic below 50 -pt extremities cold, say limbs are numb -cyanosis esp feet/hands -pt body in rigid unchanging position

glascow coma scale

3-15 less than 8 is coma, 15 is good

CSF should be

clear and colorless

bun levels

6-24

brain tumor diagnostic test

computed tomography (3D view of cranial contents and defines outlines of masses and abnormalities)

persistent vegtative state

condition in which the pt is wakeful but devoid of conscious content, without cognitive or affective mental function

locked in syndrome

condition resulting from a lesion in the pons in which the pt lacks all distal motor activity (paralysis) but cognition is intact

EOL skin

cool to touch, extremities become pale, mottled and cyanotic

dexamethasone

corticosteroid/anti-inflammatory reduces cerebral edema

warfarin

Anticoagulant -vitamin K antagonist -slow acting -INR 2-3

lorazepam

Ativan used to treat fear/anxiety

halo sign

CSF

meningitis diagnostics

CSF

EOL Breathing

Cheyne-Stokes respiration

hydromorphone

Dilaudid

Amyotrophic lateral sclerosis (ALS)

Lou Gehrig's disease progressive, degenerative disease muscle weakness/atrophy eventually resp muscles become affected, leading to resp compromise, pneumonia and death no cure

skin at EOL

MODLED

basila skull fracture

dangerous because it can cause edema and can leak CSF and problem with meningitis

extension

decerebrate posturing internal rotation of arms and wrist lower extremities will extend indicates deteriorating neuro function

polyethylene glycol

Miralax add if no BM with docusate sodium -osmotic laxative

flexion

decorticate arms to chest plantar feet implies injury to cerebral hemispheres

earliest sign of ICP

decreased LOC

Kernig's sign

Sign of meningitis; positive when the leg is fully bent at the hip and knee, and subsequent extension of the knee leads to pain

complex bereavement

Symptoms >12 months Persistent longing for deceased associated with sadness and crying Desire to die to be with deceased (suicidal thinking) Depressed mood is focused on the loss Deficits in work and social functioning beyond social and cultural norms

Parkinson's patho

decreased dopamine, which normally functions to promote voluntary muscle and sympathetic nervous system control chronic, terminal disease caused by degeneration of substantial nigra cells in basal ganglia

ventriculostomy

a catheter placed in one of the lateral ventricles of the brain to measure intracranial pressure and allow for drainage of fluidagnosia: loss of ability to recognize objects through a particular sensory system; may be visual, auditory or tactile

Babinski reflex (sign)

a reflext action of the toes; in adults is indicative of abnormalities in the motor control pathways leading from the cerebral cortex

epidural monitor

a sensor placed between the skull and the dura to monitor intracranial pressure

decerebration

abnormal body posture associated with a severe brain injury, characterized by extreme extension of the upper and lower extremities

Which assessment finding would be the nurse recognize as common in infants with Down syndrome?

abnormal heart sounds

clonus

abnormal movement marked by alternation contraction and relaxation of a muscle occuring in rapid succession

decortication

abnormal posture associated with severe brain injury, characterized by abnormal flexion of the upper extremities and extension of the lower extremities

herniation

abnormal protrusion of tissue through a defect or natural opening

tonic seizures

abrupt increase in muscle tone, loc, and autonomic changes lasting from 30 sec to several minutes

Parkinson's pt teaching

active/passive ROM -avoid concentrating on feet when walking -small, frequent meals, thickening liquids -weight weekly

clorazepate

adjunctive therapy for partial seizures

priority with meningitis

admin prescribed antibiotics

dopamine agonists

adverse effects: orthostatic hypotension, hallucinations, sleepiness, drowsiness, avoid operating machinery, move from lying to sitting slowly, give before meals

stroke assessment tool

age greater or equal to 60 bp greater 140/90 clinical TIA features (unilateral weakness increase stroke risk) duration of symptoms (longer the TIA symptoms last, the greater risk of stroke)

grief

allow expression of feelings

brain injury

an injury to the skull or brain that is severe enough to interfere with normal functioning

levodopa/carbidopa

anti-parkinson (dopamine replacement) -anti-parkinsons -give before meals -limit vasoconstriction-sit to stand slowly -side effects: nausea, emotional changes -adverse long term effects of levodopa: orthostatic hypotension, psychotic episodes, dyskinesia, twitching

vasopressin

antidiuretic hormone -desmopressin -constricting effect on arterioles -regulates BP, blood volume, osmolality -decreases water excretion -tx for DI which can result after Tx for increased ICP

pre-active death

approx 2 weeks -increased restlessness, confusion, agitation, inability to stay content in one position, insisting on changing positions frequently, withdrawal from active activities -increased periods of sleep, lethargy, decreased intake of food and liquids -beginning to show periods of apnea -seeing someone who is dead -states they are dying -req to see family -inability to hear/recover -increased swelling

decerebrate posturing

arms extended straight out and toes pointing downward

stroke risk factors

artherosclerosis hypertension anticoagulation therapy diabetes stress obesity oral contraceptives

stroke prevention

aspirin, bp control, cholesterol mgmt, smoking cessation

lorazepam

ativan -1st choice to admin in tonic-clonic seizure -may require multiple doses IV push -extra contraception -adverse: nystagmus, ataxia, slurred speech -report hematologic changes immediately

Which meds for ADHD?

atomoxetine methylphenidate dextroamphetamine

relfex

automatic response to stimuli

TBI patient positioning

avoid extreme flexion of extension of neck and to maintain the head in the midline, neural position, keep HOB elevated to 30 degrees

instruction when assisting a client w/ parkinson's to ambulate

avoid leaning forward

position (postural) sense

awareness of position of parts of the body without looking at them aka proprioception

morphine and opioid w/ ICP

be careful because it can increase ICP

when to contact local organ procurement org

before brain death is declared

anti hypertensive drugs

beta blockers calcium channel blockers ace inhibitors

hemianopsia

blindness in half the visual field

basilar fracture

blood draining from left ear and rhinorrhea after MVC fracture at base of cranium can tear meninges causing nasal leakage of CSF (rhinorrhea)

TIA symptoms

blurred vision diplopia hemianopsia tunnel vision facial droop ataxia numbness vertigo aphasia dysathria

Stroke s/s

blurred vision diplopia hemianopsia (vision affecting both eyes) tunnel vision weakness ataxia numbness vertigo aphasia dysarthria

phenytoin

treats partial, secondary and generalized tonic-clonic seizures -must floss teeth regularly (delay dev of gingival hperplasia) -10-20 therapeutic range, if less than initiate seizure precautions -usually continued for life -admin SLOW -additional contraception, not with warfarin, avoid citrus, no milk or antacids with admin, take folic acid supplements

Parkinson's s/s

tremor, muscle rigidity, bradykinesia/akinesia, postural instability

dev ages with grief/death**

understanding permanence of death

aura

unusual sensation before seizures takes place

how to identify pt with reduced kidney function

use serum creatinine or estimated glomerular filtration rate

antiseizure meds

used with caution when taking anticoagulants, acetylsalicylic acid, sulfonamides, cimetidine, and antipsychotic meds -absorption is decreased with use of antacids, calcium preparations and antineoplastic meds

most common meningitis

viral is most common; aka aseptic meningitis because no organisms are typically isolated from culture of CSF

ventroperitoneal shunt failure

vomiting distended fontanels

anticonvulsant meds

wean off gradually, abrupt removal can result in a seizure

ADHD meds

weigh weekly give in morning after breakfast eat first then give med adverse: addictive side effects: h/a, htn

menopause tx

weight bearing exercise to prevent osteoporosis

altered level of consciousness (LOC)

when a pt is not oriented, does not follow commands, or needs persistent stimuli to achieve a state of alertness

death occurs

when all vital organs and body systems cease to function in general, resp cease first and then heartbeat stops a few min after

ALS communication

writing electronic devices

ondansetron

zofran treats nausea