Exam 1 Flashcards
What are the levels of consciousness
Alert
Lethargic
Obtunded
Semi comatose
Comatose
Alert
Receptive and responsive
Lethargic
Responds appropriately but is slow and may need stimuli to remain awake
Obtunded
Difficult to arouse, requires constant stimulation to stay awake and inconsistently follows commands
Semicomatose
Requires extreme or repeated stimuli but responds with purposeful movement, does not follow commands, nonverbal
Comatose
Unconscious with no meaning response to stimuli
PERRLA
Pupils equal round react to light and accommodate- coverage and constrict
Miosis
<3mm
Mydriasis
> 7mm
Anisocoria
unequal
Diplopia
Double vision
Pinpointed pupils
Narcotics
Dilated pupils
Scopolamine patch
Amphetamines
Cough medicine
Cocaine
LSD
What are the components of EMV
Eye opening
Motor response
Verbal response
Eye opening response
4 spontaneously
3 to speech
2 to pain
1 no response
Verbal response
5 oriented to time, person, and place
4 confused
3 inappropriate words
2 incomprehensible sounds
1 no response
Motor response
6 obeys commands
5 moves to localized pain
4 flex to withdrawal from pain
3 abnormal flexion
2 abnormal extension
1 no response
Decorticate
Problems with cervical spinal tract or cerebral hemisphere
Decerebrate
Problems with midbrain or pons
Is decorticate or decerebrate worse
Decerebrate is technically worse because it signifies a more profound neurological insult affecting a lower brainstem level
What is the accommodation test
Use pen light and bring to patients nose ensuring that their pupils converge and constrict
Sensory overload
Reception of multiple sensory stimuli
Pain, lack of sleep, worry, frequent treatments, decreased cognitive ability, irritability, anxiety, restlessness, disorientation, and more.
Nurses should work to modify the environment to the patients liking, control pain, orientation cues, schedule routine of care and prepare client for procedures, and more.
Sensory Deprivation
Inadequate quality or quantity of simulation
Private rooms or confinement, isolation, loss of senses, restrictions, emotional withdrawal, drowsiness, impairment memory, disorientation.
Nurse should provide multi sensory stimuli, frequent meaningful interactions, reorient frequently, social stimulation, and more.
Presbyopia
Unable to see near objects
Cataracts
Clouding of lens
Glaucoma
Increase intraocular pressure
Macular degeneration
Portion of the retina loses function
Diabetic retinopathy
Pathological changes in the blood vessels
How to care for patients with visual impairments
Announce presence
Stay in their field of vision
Explain what you are doing
Keep pathways clear
Assist with ambulation
Presbycusis
Hearing loss due to aging
Hearing loss r/t loud noises
Working in a factory
Noise induced hearing loss
Hearing loss r/t tissue damage
Secondary to repeated infections or ototoxic medications-mycins, furosemide
interventions for auditory deficits
Cheating for impacted cerumen
Amplification of sounds or flashing lights for safety
Slower speech and tones
Communication boards
Short sentences
What are red flag symptoms of a headache
Fever
Weight loss
Altered mental status
Weakness
Papilledema
Proximal artery tenderness
Severe headache triggered by intercourse, cough, or exertion
Tension headache
Usually associated with a stressful event/ muscular contraction in the neck and scalp
Pressing or tightening pain
Occipitofrontal location; bilateral pain
Mild to moderate intensity
Lack of effect of physical activity
Nurse should give necessary medications, encourage rest, massages, etc.
Cluster headache
Severe and unilateral
Sharp unilateral orbital, supraorbital, or temporal pain accompanied by autonomic symptoms on the affected side.
Patient becomes restless
Episodes can last 15-180 minutes and occur in increments
Nurses should utilize supportive care and pain medication
Migraine
Severe disabling, unilateral headaches
Described as pulsating
Sensitivity to light, sound, and smells, nausea, stiff neck
Nursing care includes modifying the environment, start IV, and manage the symptoms
