Nursing Science Flashcards
GCS consists of
Eye opening response
Verbal response
Motor response
Eye opening response
4
Eyes open spontaneously
Eye opening response
2
Eyes open to pain (not applied to face)
Eye opening response
3
Eyes open to verbal command, speech, or shout
Verbal response
5
Orientated
Eye opening response
1
No eye opening
Verbal response
4
Confused conversation but able to answer to the questions
Verbal response
3
Inappropriate responses, word discernible
Verbal response
2
Incomprehensible sounds or speech
Verbal response
1
No verbal response
Motor response
6
Obeys command for movements
Motor response
5
Purposeful movement to painful stimulus
Motor response
4
Withdraws from pain
Motor response
3
Abnormal (spastic) flexion, decorticate position
flexes elbow and wrist while
extending lower legs to pain
Motor response
2
Extensor (rigid) response, decerebrate posture
extend upper and lower
extremities to pain
Motor response
1
no motor response
Minor brain injury points
13-15 points
Moderate brain injury points
9-12 points
Severe brain injury points
3-8 points
Signs & Symptoms of Increased in ICP (6)
Headache
Nausea/Vomiting
Altered level of consciousness
Papilloedema
Dilated pupils
Cushing reflex (late signs)
– Bradycardia
– Widening of pulse pressure
– Altered breathing pattern
Goals for ischemic stroke
Achieve timely recanalization of the
occluded artery and reperfusion of the ischemic tissue
Optimise collateral flow
Avoid secondary brain injury
Goals for Haemorrhagic Stroke
MAP – ICP = CPP(>60 mmHg)
CPP: CEREBRAL PERFUSION PRESSURE
MAP
* Normovolemia
* Maintain BP
ICP
* CSF Drainage
* Osmotic Therapy
* Venous Drainage
CPP
* Ventilation &
Oxygenation
* Control cerebral
metabolism
Indication for CLC (7)
Indications for CLC:
Hypoxia
Metabolic imbalance such as hypoglycaemia
Falls or trauma to the head
Unresponsiveness
Neurological disease process e.g. stroke, brain tumours,
Epilepsy
New admission to form a baseline assessment
Medical conditions that may affect conscious level assessment (8)
- periorbital swelling/maxillofacial injuries
- glaucoma/ cataract/ eye disorders
- difficulty in hearing
- sedation and/or analgesia prescribed (if any)
- alcohol intoxication
- dysphasia/aphasia
- tracheostomy/ intubated
- high spinal injuries/ paralysis
Pain stimulus
i) pressure on lateral inner aspect of third or fourth finger as shown or
nailbed if eyes remain close OR
ii) trapezius squeeze if eyes remain close OR
iii) pressure over the supra-orbital notch/ridge using the thumb if eyes still remain close
Document ‘T’ if patient has
tracheostomy or ETT;
Document ‘D’ if patient has
dysphasia.
Motor strength
5
able to overcome gravity and maximum resistance
Motor strength
4
able to overcome mild to moderate resistance
Motor strength
3
able to lift up the arm but unable to overcome the resistance (>anti-
gravity strength)
Motor strength
2
able to moves along the non-gravity surface but unable to lift up
(<anti-gravity strength)
Motor strength
1
visible muscle movement/muscle contraction
Any decrease of GCS score ≥_____
suggests possible underlying neurological
deterioration and must be reported to the doctor in charge. Thus, it is
always important to refer to the GCS baseline of patient.
2
Care of patient with EVD
- Ensure HOB 30degress unless contraindicated
- Maintain patient’s head and neck in neutral position.
- Monitoring of patient as ordered (e.g. Hourly, 4-hourly or 8-hourly)
Levelling of EVD System
Position the patient with HOB 30degrees or as ordered by doctor.
Adjusts the height of the EVD such that its zero mark on the EVD scale level with the #tragus of ear using the carpenter’s spirit level.
(#When the patient is lying on one side, this anatomical reference point becomes at the midsagittal line (between the eyebrows).
Adjust the collection drip chamber aligned to the desired height as ordered (e.g. 10cm above tragus of ear).
*Always level transducer and drainage chamber
- at beginning of shift and
- if change in position of bed.
(*applicable in ICU setting)
Ensure the correct height
setting of EVD system to
prevent over drainage or
under drainage of CSF
Characteristics of normal
CSF
Clear & colourless
Characteristics of
abnormal CSF (Xanthochromia
discoloured)
usually pale yellow, due to
breakdown of RBC from previous bleeding
Characteristics of
abnormal CSF (Turbid, Cloudy)
Occurs due to presence of CNS
infection e.g.meningitis.
Characteristics of
abnormal CSF (Bright red)
indication of an acute hemorrhage
RAPIDS TOOL
Airway (5)
Assess for the signs of airway obstruction (look/listen/feel)
Perform head tilt chin lift or jaw thrust
Place patient on the side
Insert artificial airway (e.g. oropharygneal / nasopharyngeal airway)
Perform suctioning
RAPIDS TOOL
Breathing (9)
Count respiratory rate
Assess breathing pattern (e.g. regularity/depth)
Assess chest movement
Check for cyanosis
Measure oxygen saturation level
Auscultate chest for breath sound
Place patient in head-up position
Initiate oxygen
Titrate oxygen (keep SpO2 > 94%; For COPD, keep SpO2 90-92% or at baseline)
RAPIDS TOOL
Circulation (12)
Count pulse rates
Palpate pulses (e.g. regularity / strength)
Measure blood pressure
Check for peripheral skin (e.g. colour/temperature/moisture)
Measure capillary refill time (normal < 2 seconds)
Measure body temperature
Check urine output (oliguria < 0.5ml/kg/hr)
Lower patient head of bed position
Establish intravenous (IV) access
Prepare or administer IV Normal Saline 0.9%
Attach cardiac monitor
Perform 12 lead electrocardiogram (ECG)
RAPIDS TOOL
Disability (3)
Assess level of consciousness using AVPU or GCS
Examine pupils
(size/equality/reaction)
Monitor blood glucose level
RAPIDS TOOL
Expose/Examine (6)
Expose body for physical examination (e.g. inspection/ palpation/percussion/ auscultation )
Examine invasive catheter/ tube/ lines/ drainage
Examine pain (e.g. PQRST)
Examine patient’s recorded chart or notes (e.g. history, baseline, trend)
Examine prescribed medicine
Examine investigations result (e.g. laboratory/diagnostic)
