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