BPC Exam 1

Levels of Consciousness

1. alert

2. lethargic

3. obtunded

4. stupor (semi-comatous)

5. coma

6. delirium

7. dementia

Alert

patient is awake and attentive to normal stimuli

Lethargic

(Somnolent) patient arouses with stimuli

decreased awareness

orientated & not confused

Obtunded

patient is difficult to arouse

confused when awake

unproductive interactions

Stupor

(semi-comatous)

unable to interact

falls asleep w no stimulus

responds to unpleasant stimuli

Coma

patient cannot be aroused

may or may not have reflexes

Delirium

patient demonstrates offensive/talkative behaviors

States of disorientation

• irritability

• agitation

• paranoia

  • hallucinations

Dementia

No change in alert state

brain is deteriorating

decreased memory loss

Determine levels of consciousness

use progressive levels of stimuli to determine level of consciousness or decreased alertness

Ways to increase patients alertness

position from recumbent to sitting

open curtains

turn on tv

put cold washcloth on forehead

Cognition

“process of knowing includes both awareness and judgement”

Cognitive testing

• assessment of attention

• orientation

• memory

• abstract thought

• ability to perform calculations or construct figures

  • judgement

Attention

ability to attend to specific task

tested by asking patient to repeat series of numbers or spell backwards

Orientation

patients awareness of person, place, or time

Documented by O x 3

Orientation questions

person, place, time

Memory

• Immediate recall

• Short-term memory

• Long memory(remote)

Calculation

ability to perform verbal or written math problems

Construction

ability to construct 2-3 dimensional shape

Abstraction

ability to reason in abstract rather than literal or concrete fashion

Explain “the early bird gets the worm”

Judgement

ability to reason

Basic Sensation

seeing, hearing, touching (light touch, proprioception pressure, pain)

Assess hearing

talking to patient

“hearing aids?’

“completely deaf?”

“can they sign?”

Assessing vision

vision chart (Snellen)

peripheral feild, depth perception

“does pt have glaucoma, cataracts, blind in 1 or both?”

Proprioceptors

Responsible for deep sensations such as

• position sense

• awareness of joints at rest

• kinesthesia

• vibration

kinesthesia

movement awareness

Exteroceptors

receive stimuli via external environment via skin & subcutaneous tissue

• perception of pain

• temp

• light touch

• pressure

Pain

unpleasant sensory or emotional experience associated with actual or potential tissue damage

Pain screen

quantitative rating of intensity of pain

Pain Assessment

1. location (exact area, radiate?)

2. intensity

3. duration

4. effects on performing activities of daily living

5. sleep patterns, postures, surfaces

6. psychosocial effects (work/hobbies)

factors alleviate/aggravate

1. symptom onset?

2. constant or intermittent?

3. what makes worse/better?

4. worse when awake or as day progresses?

5. Inc w/ sneezing, coughing

2 types pain management

pharmacologic interventions

non-pharmacologic interventions

Pharmacologic interventions

pain meds can be given in multiple ways

• IV

• IM

• orally

• Continuous wound infection CWI

• topical cream/ointment

• topical patch

CWI

(continuous wound infection) local anesthesia given after surgery that will deliver low dose stream at surgical site

sedating medication

ICU/combative pts given sedatives to control anxiety and agitation

symptoms of pain meds or sedation

lethargic, Nassau, confused, disoriented, sleepiness, slurred speech, Dec balance, slow shallow respirations, slow HR, hallucinations

Relaxation techniques

• visual imaging

• deep breathing

• Jacobsons Technique

Non-pharmacologic interventions

application of physical agent modalities (ice, heat, tens)

positioning

massage

distraction techniques

relaxation techniques

Exercise!!

Jacobson’s Technique

(Progressive relaxation techniques) tightening and relaxing specific muscle groups in sequence like distal to proximal

Comprehensive Pain Management

interdisciplinary approach: getting the nurse to pre-medicate at pt prior to rx

6 vital signs

1. Body temp

2. heart rate

3. Pulse oximeter

4. Blood pressure

5. Respiration Rate

   1. Pain

When to take vitals?

prior to treatment

Before/after exercise

when patient is in distress

Diaphoresis

sweating to unusual degree, clammy

Erythema

redness of skin caused by increased blood flow

Normal Body temp

96.8 to 99.3 (98.6)

if temp is >100deg.

No treatment

Body temp sites

oral, rectum, axilla, ear, temporal artery

Most common? Oral & rectum

Hyperthermia

abnormally high body temp

Hypothermia

Abnormally low body temp

Pulse

Indirect measure of contraction of the left ventricle

Normal Pulse Ranges

Adult: 60-100 bpm

Child: 70-130 bpm

Newborn: 100-150 bpm

Tachycardia

More than 100 bpm

Bradycardia

Less than 60 bpm

Patency

refers to the openness of the arterial vessels

Pulse sites

1. temporal

2. carotid

3. brachial

4. radial

5. femoral

6. popliteal

7. dorsal pedal

8. posterior tibial

Most common? Carotid & Radial

Descriptions of Pulse

• Strong

• Bounding

• Thready

• Weak

• Irregular

Thready Pulse

weak force to each beat, barely perceptible-easily lost with slight pressure

Bounding pulse

very strong, hyperactive

Normal HR response to exercise

• Inc/Dec. w Inc/Dec of exercise

• Return to resting HR within 3-5 min after ex. has stopped

Red flags for HR

• Fatigue

• Light-headedness

• Exercise Intolerance

• Cognitive impairment

• Arrythmias

Arrythmias

An abnormality in the timing or pattern of the heartbeat

Pulse oximeter

measure peripheral blood oxygen levels and monitors pulse rate

Normal Ox. saturation

95-100%

Red flags for O2 levels

• confusion

• wheeing

• HR changes

• Diaphoresis

• Clubbing

• Nail bed color changes

Tools for BP

sphygmomanometer and stethoscope

Systolic pressure

contraction of left ventricle

Korotkoff’s Level 1 sound

systolic pressure

Korotkoff’s Level V sound

Diastolic pressure

Diastolic pressure

rest period of the heart in between beats

Do not take BP on arm with

IV, Mastectomy, abnormally high/low muscle tone

Proper BP technique

left arm

legs uncrossed

arm at heart level

Normal BP

less than 120/ less than 80

Pre-HTN

120-129 and less than 80

Stage 1 HTN

130-139 or 80-89

Stage 2 HTN

greater than or equal to 140 or greater than or equal to 90

HTN Crisis

Greater than or equal to 180 and/or greater than 120

Hypertension

when pressure in blood vessels is too high

Hypotension

Systolic pressure is below 100 mmhg

syncopy

fainting or passing out

Orthostatic Hypotension

(postural hypotension) decrease of BP upon sitting/standing

Normal response of BP to exercise

Higher BP in R UE than the L UE

Diastolic remains abt the same or Inc 10-15mmhg

Respiration

Pulmonary ventilation

Normal respirations

Adults: 12-18 breaths per min

Infants: 30-50 breaths per min

Pulmonary Auscultation

listening for sounds in the lungs

Apnea

absence of breathing

Dyspnea

labored breathing

Orthopnea

shortness of breath when lying down

Stridor

heard over the trachea, high pitch sound, inspiration, obstruction, sounds like wind blowing or barking

Ex: Croup

Wheezing

whistling sound, expiration, narrowing of airways

Ex: Asthma

Rhonci

snoring or gurgling sound, expiration, caused by mucus obstruction, usually clears w coughing

Ex: COPD, PNA, chronic bronchitis

Rales (Crackles)

bubbling sound, inspiration, small airways fill w fluid

Ex: CHF, pulmonary edema

Cheyne-Strokes Respiration

abnormal pattern of breathing that consists of cycles of Inc. respiration and deeper respirations followed by shallower resps or apnea

Seen in people who are dying, HF or stroke

Documentation

Temp- route taken

HR- position of PT, which extremity, activity

Pulse Ox- room air or supplemental O2, how much O2 being delivered, adverse symptoms

BP- which arm, potion of PT, activity

RR- position of PT, activity

Purpose of changing positions

• prevent contractures

• relieve pressure to skin

• relieve pressure to organ system

Contracture

shortening and hardening of muscles, TENDONS, or other tissue often leading to deformity and rigity of joints

blanching

turning white

Intact sensation respositioning

reposition every 30 min- 2 hours for a patient that can’t move actively

impaired sensation repositioning

reposition every 15 - 10 min if sensory impaired and if sitting everyone 30-90 sec each time

What to avoid in positionging

avoid flexion, excessive rotation, hyperextension of any joints

avoid donut cushions