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Neuro-level of consciousness
LOCthe most sensitive clinical indicator of a change in neurological status and oxygenation status Consciousnesslevel of awareness: self; environment; responses to environment Evaluate the amount stimulus needed to get a response
Verbal Tactile Painful
Neuro-level of consciousness
Glasgow Coma Scale Developed as a method to standardize observation of responsiveness in patients with traumatic brain injury Parameters
Neuro-Pupils
Normal : 2-6 mm Abnormal: Significant change is more than 1 mm Pinpoint & non-reactivecould be a lesion or medication response (morphine or pilocarpine) Midsize (2-6mm) & non-reactivemidbrain lesion Unilateral large (>6mm) & non-reactivepressure on the occulomotor nerve on the same side Bilateral large (>6mm) & non-reactivebrainstem lesion or medication response (atropine, epi)
Neuro-Pupils
Equality
Abnormal: 50% of population are unequal >1mm or Change from baseline Call neurosurgeon or neurologist Shape Oval may precede dilated pupil indicating oculomotor pressure Irregular may be from cataracts or implants Position Abnormal : may deviate to the side of injury
Neuro-Pupils
Reactivity to light Normalbrisk, bilateral Abnormal
Cranial Nerve
Function
Assessment
1. Olfactory
2. Optic 3. Oculomotor
Sensory
Sensory Motor
Odors
Visual acuity / visual fields Extraocular movements pupilary reaction to light & accommodation Extraocular movements Sensation in forehead, jaw, cheeks & chin, mastication Extraocular movements Taste / movement of facial muscles Hearing acuity & balance Taste / movement of pharynx, gag reflex
10. Vagus
Mixed
Neuro
Assess grips, shoulder movement Assess leg movement Have pt push foot against your hand (like you are
stepping on the gas) Look for symmetry, equal strength, equal movement, sensation Evaluate for weakness, sensation loss, inability to follow commands
Neurological Assessment
Compare baseline information to current assessment Changes in personality are a BIG hint something is going on
Neuro Respiratory Cardiac
Cardiovascular Assessment
Heart Sounds S1 (first heart sound) closing of the valves [mitral before tricuspid] the lubb sound S2 (second heart sound) closing of aortic & pulmonic valves, the dubb sound Extra heart soundscan be before the lubb/dubb or after
Cardiovascular Assessment
Murmur, rubs, clicks
Murmurflow across either an incompetent or stiff valve Rubsscratchy, scraping soundpericarditis Clicksartifical valves
Cardiovascular Assessment
Evaluate central and peripheral perfusion
Peripheral cyanosiscoldseen in fingertips, toes;
associated with hypoperfusion or vasoconstriction Central cyanosiswarmcyanosis seen in lips, tongue, mucous membranesis associated with a drop in oxygenated hemoglobin
normal
CardiovascularEdema Scale
0 = no depression in tissue +1 = small depression in
tissue, disappears in less than one second +2 = depression in tissue, disappears in less than 1-2 seconds +3 = depression in tissue, disappears in less than 2-3 seconds +4 = depression in tissue, disappears in greater than 4 seconds
CardiovascularEdema
Note the location of edema Facialseen in allergies (anaphylaxis), steroids, renal disease Dependentright ventricular failure Generalized edema (anasarca)end stage heart failure, end stage renal failure, severe hyperproteinemia
Cardiovascular Assessment
Peripheral pulses Assess radial Assess Dorsalis pedis & posterior tibialis Check for equality, quality, rate & regularity Use a doppler if you cannot palpate pulsesDO NOT chart unable to palpate pulses unless you have assessed using a doppler and other findings correlate with lack of pulse
CardiovascularPulse Amplitude
0 = not palpable
1+ = weak and thready, easily obliterated 2+ = normal, not easily obliterated
Venous
Crampy pain Homens sign in thrombophlebitis Normal (may be difficult to palpate due to edema) Normal or ruddy Warm Present; may be severe
Cardiovascular Assessment
IV sites and IV fluids Note where sites are and what they look like
Assess for infiltration and infection, patency Note date, time of venipuncture and size of the catheter Are the IV fluids what was ordered and are they running at the rate ordered? If a titrated medication or running at a calculated dosecheck to make sure infusion is correct Check date on tubingno datechange it!
Cardiovascular Assessment
Monitor? Telemetry / hard wire?
What is the rhythm? Rate? Regular? What are the alarm parameterschecked and audible? When were the electrodes changed? Heart rate versus pulse rate
Respiratory Assessment
Oxygenation and ventilationthe focus of respiratory assessment
Rate, rhythm of respirations and symmetry of chest wall movement
Respiratory Assessment
Note LOCrestlessness or confusion usually first sign
of hypoxia What is the work of breathing? Should be an unconscious eventis the patient having to think and work at breathinglaboring?
Pursed lip breathingseen in dyspneamay be
Respiratory Assessment
Rhythm Description Eupnea
Bradypnea
Rate 12-20 minute and normal depth of ventilation; regular with an occasional sigh Slow less than 10 per minute NORMAL
Possible Causes
Depression of resp center with opium (narcotics), alcohol or tumor Sleep Increased intracranial pressure CO2 narcosis Metabolic alkalosis
Tachypnea
Restrictive lung disease Pneumonia Pleurisy Chest pain Fear, anxiety Respiratory insufficiency
Hypopnea
Deep sleep Heart failure Shock Meningitis Central nervous system depression Coma
Hyperpnea
Exercise Hypoxia Fever Hepatic coma Midbrain or pons lesion Acid-base imbalance Salicylate overdose
Cheyne-Stokes
Intracranial hypertension Heart failure Renal failure Meningitis Cerebral hemisphere damage Drug overdose
Kussmaul
Apneustic
Cluster
Periods of apnea alternating with a series of breaths of equal depth; breathing may be slow and deep or rapid and shallow
Lack of any pattern to ventilation
Meningitis Encephalitis Lesion of the lower pons, upper medulla Intracranial hypertension
Ataxic
Brainstem lesion
Obstructive
Apnea
Lung Sounds
Findings
Adventitious sounds
Description
Possible etiology
Fine crackles
Series of short explosive high pitched sounds heard just before the end of inspiration; result of rapid equalization of gas pressure when collapsed alveoli or small terminal bronchioles suddenly snap open; similar sound to that made by rolling hair between fingers just behind ear
Series of low pitched sounds caused by air passing through airway intermittently occluded by mucus, unstable bronchial wall, or fold of mucosa; evident on inspiration and at times expiration; similar to blowing through straw under water; increase in bubbling quality with more fluid
Interstitial fibrosis (asbestosis), interstitial edema (early pulmonary edema), alveolar filling (pneumonia), loss of lung volume (atelectasis)
Coarse crackles
Congestive heart failure, pulmonary edema, pneumonia with severe congestion, chronic obstructive pulmonary disease (COPD)
Rhonchi
Continuous rumbling, snoring or rattling sounds resulting from obstruction of large airways with secretions; most prominent on expiration; change often evident after coughing or suctioning
Wheezes
Continuous high pitched squeaking sound caused by rapid vibration of bronchial walls; evident on expiration but possibly evident on inspiration as obstruction of airway increases; possibly audible without stethoscope
Stridor
Continuous musical sound of constant pitch; result of partial obstruction of larynx or trachea
Creaking or grating sound caused by roughened, inflamed surfaces of the pleura rubbing together; evident during inspiration and expiration and no change with coughing; usually uncomfortable, especially on deep inspiration
Respiratory Assessment
Assess nailbeds Colorcyanosis? Clubbingindicates chronic decrease in O2 supply to body tissues
Normal angle between nailbed and nail = less than 180 degrees Early clubbingangle = to 180 degrees Late clubbingangle greater than 180 degrees
Normal
Early clubbing
Late clubbing
Cough
Use of accessory muscles Intercostal retractions
Oxygen Therapy
Nasal Cannula 24 to 40% at 1-6 L/min
Oxygen Therapy
Simple face mask 40-60% at 5-8 L/min
Oxygen Therapy
Partial re-breather mask 60-75% at 6-11 L/min (maintain liter flow to keep reservoir bag 2/3 full during inspiration)
Oxygen Therapy
Non-rebreather mask 80-95% (maintain liter flow to keep reservoir bag 2/3 full during inspiration)
Oxygen Therapy
Venturi Mask 24 to 55% (usually 4-10 L/min; provides high humidity)
Oxygen Therapy
Aerosol Mask, Face Tent, Trach Collar 24-100% with flow rates of at least 10 L/min; provides high humidity
Oxygen Therapy
T-Piece 24-100% with flow rates of at least 10 L/min; provides high humidity
GI Assessment
History Pain? Nausea and vomiting? Change in bowel pattern? Change in appetite?
GI Assessment
Cullens Sign Bruising around the umbilicusindicates intraabdominal bleeding Grey-Turners Sign Bruising of the lower abdomen and flank area indicates retro-peritoneal bleeding
GI Assessment
Inspection first
Auscultation secondlisten all four quads (best
locationRLQ)
Bowel sounds are not the sole indicator of bowel
GI Assessment
Palpationlast Light palpation is one handed and superficial Deep palpation is bimanual; used to palpate liver, aorta, parts of the colon Rebound tendernesssudden removal of palpating hand after deep palpation. Presence of pain = peritoneal irritation
GU Assessment
Historypain, problems with urination, changes in
what does that look like, how much? Any smell? Staples or sutures?
Tubes
NG tubessingle or double lumen? Suction? What draining? Placement checked? Chest tubewhere? Suction? Draining? Check volume