Chapter 10- Assess Level of Consciousness Flashcards
Early in your assessment, you will need to evaluate _____
The patient’s level of consciousness (LOC)
The patient’s Level of Consciousness (LOC) can tell you a great deal about
The patient’s neurologic and physiologic status
The level of consciousness will help you determine if the patient has a life-threatening injury or if the patient will be capable of providing reliable information about his or her own condition
The brain requires a constant supply of ______ and ____ to function properly
oxygen and glucose
In the primary assessment, you need to ascertain only the ______ LOC
Gross
What is gross LOC ?
refers to a basic assessment of a person’s awareness and responsiveness to their surroundings
The _____ scale is used to assess the patient’s LOC
APVU
The APVU scale tests a patient’s responsiveness based on the following criteria:
Awake and alert
Responsive to verbal stimuli
Responsive to pain
Unresponsive
What does it mean for the patient to be awake and alert ?
The patient’s eyes open spontaneously as you approach, and the patient appears to be aware of you and responsive to the environment
The patient is awake, appears to follow commands, and the eyes visually track people and objects
What does it mean for the patient to be responsive to verbal stimuli?
The patient is not alert and awake.
The patient’s eyes do not open spontaneously.
However, the patient’s eyes do open when you speak to him or her, or the patient is able to respond in some meaningful way when spoken to- for example by moaning, speaking, or moving
A patient who does not respond to your normal speaking voice, but responds when you speak loudly is considered to be:
responding to loud verbal stimuli Responsive
What does it mean for a patient to be responsive to pain?
The patients does not respond to your questions but moves or cries out in response to painful stimulus
There are ______ and _______ methods of applying a painful stimuli
appropriate and inappropriate
Some methods may not give an accurate result if a _______ is present
spinal cord
List the methods of gauging of a patient’s responsiveness to painful stimuli:
Gently or firmly apply pressure on or pinch the patient’s sternum
Gently but firmly apply pressure or pinch the posterior edge of the patient’s mandible (lower jaw)
Gently but firmly pinch the patients trapezius muscle on top of the shoulder/collar bone
Apply upper pressure along the ridge of the orbital rim along the underside of the eyebrow (without applying pressure to the eyeball)
What does it mean for a patient to be unresponsive?
The patient does not respond spontaneously or to verbal or painful stimulus.
Unresponsive patients usually have no ___ or ______
cough or gag reflex
Unresponsive patients lack the ability to ______
protect the airway
If you are in doubt about whether a patient is truly unresponsive, you should _____
assume the worst and treat appropriately
When using the APVU scale, be sure to note ___
Note how the patient responded
If the patient is hard of hearing, how should you try to stimulate them ?
Tap with your fingers repeatedly
If the patient responds, note that the patient is hard of hearing but responds to being tapped
A patient who ____ or ______ is responding to the painful stimulus.
Moans and withdraws
For the patient who responds to painful stimulus, be sure to note the _______ and _______ of the stimulus
Type & Location of the stimulus
The point is not to cause as much pain as possible, but to see if the patient responds or withdraws from the sensation of pain where you caused it.
True
Note that a patient who remains _____ and _______ is considered unresponsive
Flaccid (limp, loose, droopy, and wrinkly)
does not move or make a sound
For a patient who is alert or responsive to verbal stimuli, next evaluate _______
Orientation
Define orientation.
Orientation tests a patients mental status by checking his or her memory and thinking ability.
The most common test evaluates a patients ability to remember 4 things:
Person (remember his or her name)
Place (identifies his or her current location)
Time (year, month, and day of the week)
Event (what happened: MOI and NOI)
Why is paramount to assess all four questions?
The questions were not selected at random, they assess 4 different categories.
What do you ask to evaluate long term memory ?
Person (patients name)
Place (his or her location)
What do you ask to evaluate intermediate memory?
Year or month
What do you use to evaluate short-term memory ?
Day of the week and event (what happened)
If the patient knows these facts, the patient is said to be:
alert and fully oriented
alert and oriented to person, place, time, and event
alert and oriented x4
It is important to determine, if possible, the patient’s ________ to use as a baseline
normal mental status
Any deviation from alert and oriented to person, place, time, and event, or from a patient’s normal baseline is considered __________
Altered mental status
What circumstances may cause a patient to have a baseline of not being fully alert and oriented ?
Ongoing illness
history of stroke
traumatic brain injury
developmental delay
Alzheimer’s disease
If you determine that the patient has any indicators for spinal motion restriction, what should you do ?
Ensure the patient’s cervical spine is manually stabilized by either you or another provider
If it is not possible to both manually stabilize the patient’s cervical spine and continue your assessment of identifying life threats, what should you do ?
Do your best to ensure the patients spine remains remains in a stable position while you continue your primary assessment
You should complete your primary assessment prior to _________
applying a cervical collar
What are the two main indications for spinal immobilization?
Blunt trauma (injury of the body by forceful impact can lead to bleeding under the skin)
Penetrating trauma (open wound injury in which an object pierces the skin)
More specifically,blunt trauma accompanied by any of the following is an indication for spinal immobilization:
Altered mental status
Intoxication (alcohol or drugs)
Difficulty or inability to communicate
Or, blunt or penetrating trauma with anya of the following could also be indications for spinal immobilization
Pain or tenderness on palpation of the neck or spine
Patient report of pain in neck or back
Paralysis or neurological complaint (numbness, tingling, partial paralysis of the legs or arms)
Define a distracting injury.
Any injury that distracts the patient’s attention from others injuries he or she may have, even severe injuries.
Give an example of a distracting injury.
A painful femur or tibia fracture that prevents the patient from noticing neck or back pain
