Assessment broken down by system Flashcards
complex intergration of mental processes and intellectual function for the purposes of reasoning, learning, memory and personality.
- reasoning is a high level thinking process that allows an individual to make decision and judgments
- memory is the ability of an individual to retain and recall information for learning or recall of past experiences.
- personality is the way of individual feels and behaves, often based on how he or she thinks
cognition
disoriented to surrounding, may have impaired judgement, may need cues to respond to commands.
confused
drowsy, needs gentle verbal or touch simulation to initiate response
lethargic
responds slowly to external stimulation and needs repeated stimulation to maintain attention and response.
obtunded
responds only minimally with vigorous stimulation and may only moan as a verbal response.
stuporous
no observable response to any external stimuli
comatose
responds readily, but may be confused
alert
anxiety, confusion, and restlessness can be signs of ______ .
hypoxia
A blood pressure above baseline can indicate what?
intracranial pressure
commonly used set of questions for screening cognitive function. may indicate presence of cognitive impairment.
mini mental state examination (MMSE)
is a standardized evidence based tool that enables non-psychiatrially trained clinicians to identify and recognize delirium quickly.
confusion assessment method (CAM)
- acute, fluctuating with sudden onset
- multiple possible causes, may be reversible
- Tx based on cause
- reorient and provide safe environment
delirium
- chronic progression with slow onset
- irreversible, unknown cause
- last months to years
- tx symptoms
- use validation, do not argue
- safe environment
- observe for hallucinations and delusions
- can’t be oriented
dementia
- understand the difference b/t delirium and dementia
- prevent client from experiencing hypoxia
- prevent fluid and electrolytes imbalances
- be exact with medication dosage of opioids, steroids, psychoactive drugs, and general anesthesia.
- teach clients to avoid substance use
- promote positive lifestyle behaviors
- teach older adults to stimulate the intellectual portion of their brain with new learning activities.
interventions to promote cognition
- predictable routines
- simple instructions
- familiar people and objects
- appropriate environmental stimuli
- focus on safety
- foster communication
- delirium and mild dementia reorient to person, place, time
- collaborate with interdisciplinary team to determine the cause.
interventions with abnormal assessment of cognition
clients with moderate to severe dementia _____ be oriented because of the chronic confusion.
cannot
the intactness of the structure and function of the integument and mucous membranes.
tissue integrity
- assess for changes in skin color, moles/lesions, excessive skin dryness, bruising, and hair loss or brittle nails.
- document existing tissue impairment in detail.
- stage pressure areas
- monitor serum albumin and prealbumin levels.
assessment of tissue integrity
- SBAR
- use specific language
- report last time observed well
- report any medication given
- report recent lab values or diagnostic test completed
reporting your observation
a chronic health condition is one that has existed for at least 3 months.
chronically ill
- be patient, relaxed, and unhurried
- allow plenty of time for response.
- be alert for signs of fatigue.
- take advantage of natural opportunities to assess
- ensure assistive devices are in place and functioning
- proceed in a manner to keep position changes to a minimum
- proceed from lesser invasive areas to more especially for older adults with confusion
examiner considerations when assessing older adults
- physical assessment begins immediately upon entering the room
- note skin color and gait as well as the caregiver response and caregiver/child interaction
- perform assessment as opportunity presents.
- if infant is sleeping, listen to lungs and heart sounds
- use play therapy, offer choices
- save invasive or pain assessment until end
considerations for children
unequal pupils are indicative of what?
brain swelling, hemorrhage or head injury
what is a decrease in pupillary reaction indicative of ?
Intracranial pressure or sedation
what medication can causes the pupils to dilate ?
atropine
what medications can cause the pupils to shrink in size?
opioids
