Practice Terms Flashcards
Levels of consciousness
(1) Alert
(2) Lethargic (somnolent)
(3) Obtunded
(4) Stupor or semi coma
(5) Coma
Lethargic
Not alert, drifts off to sleep, drowsy, thinking slow and fuzzy, inattentive, loses train of thought, spontaneous movement decreased.
Obtunded
Transitional state not always included. Sleeps mostly, difficult to arouse (needs loud shout or vigorous shake), confused, converses in monosyllables/mumbles/incoherent, requires constant stimulation even for marginal cooperation.
Stupor or semi coma
Spontaneously unconscious, responds only to vigorous shake or pain, has motor/reflux response to pain, mumbles, groans, moves restlessly.
Coma
Completely unconscious, no response to pain or any internal/external stimuli. Light coma has some reflux activity. Deep coma has no motor response.
Levels of stimulus
Name called, name called in loud voice, light touch on arm, vigorous shake of shoulder, pain applied.
ABCT
Appearance, Behavior, Cognition, Thought process.
Acute confusional state (Delirium)
Clouding of consciousness, inattentive, makes incoherent conversation, impaired recent memory, agitated, visual hallucinations, disorientated, confusion worse at night when stimuli decreased.
Palpation
Assesses texture, temperature, moisture, organ location and size, swelling, vibration, pulsation, rigidity, spasticity, crepitation, presence of lumps or masses, presence of tenderness or pain.
Intradermal
Use tuberculin syringe (0.01 to 0.1 mL) with five gauge needle (26 to 27) in lightly pigmented, thin skinned, hairless sites (inner surface of mid forearm or scapular area of back) at a 5 to 15 degree angle with bevel up.
Subcutaneous
Use 3/8 to 5/8 inch, 25 to 27 needle, or insulin syringe of 28 to 31. Inject no more than 1.5 mL. For average client use 45 to 90 angle, for obese client use 90 degree angle.
Intramuscular
Use needle 18 to 27 (usually 22 to 25 gauge), 1 to 1 1/2 inches long, inject at 90 degree angle. 1-3 mL. If greater amount used divide into 2 syringes and use 2 sites.
Z-track
Type of IM that prevents medication from leaking back into subcutaneous tissue. Often used for medications that cause visible and/or permanent skin stains.
Intravenous
Use 16 gauge for trauma clients. 18 gauge for surgical clients. 22 to 24 gauge for children, older adults, medical clients, and stable postoperative clients. Peripheral veins in arm or hand. Ask which site is preferred. Neonates, veins of head, lower legs, feet. Immediately monitor for therapeutic and side/adverse effects.
Epidural
Catheter advanced through needle that is inserted into epidural space at the level of 4th and 5th vertebrae.
Oral medication
Highly variable absorption. Inactivation can occur by GI tract or first pass effect. Client must be cooperative, conscious and have intact gag reflex.
Acute dystonias
Spastic movements and muscle rigidity.
EPS
Extrapyramidal symptoms or abnormal body movements.
Dexamethasone (Decadron)
Steroid that may increase blood glucose.
Thrill
Continuos palpable sensation, like the purring of a cat.
Borborygmi
Audible abdominal sound produced by hyperactive intestinal peristalsis.
Vocal fremitis
Vibrations caused by sound waves that can be palpated externally.
Tactile fremitis
Tremulous vibration of the chest wall during breathing that is palpable on physical examination.
Clubbing
Bulging of nail base due to insufficient oxygenation. Seen with emphysema and congenital heart disease.
