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NUR1112- Nursing > 5: Glasgo coma scale > Flashcards

5: Glasgo coma scale Flashcards

1
Q

List the 3 behaviours assessed in the glasgow coma scale

A

Eye opening response
Best verbal response
Best motor response

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2
Q

How many points are associated with each response?

A

Eye opening response= 4
Best verbal response= 5
Best motor response= 6

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3
Q

GCS under 8=

A

comatose state so start to worry

- potentially intubate

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4
Q

Max and min GCS scores?

A 
max= 15
min= 3
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5
Q

Name some focus areas of a neurological health history interview

A
  • headache
  • head injury
  • dizziness and vertigo
  • seizures
  • muscle control
  • senses
  • speech
  • memory
  • cognition
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6
Q

What are some examples of question for a focused neurological health history examination?

A
  • When?
  • What does it feel like?
  • Witnessed?
  • Mechanical injury?
  • How often?
  • Associated symptoms?
  • medications?
  • bladder and bowel control?
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7
Q

What is arousal dependant on?

A

the reticular activating system
- network of neurons located in the brain stem that project anteriorly to the hypothalamus to mediate behavior, as well as both posteriorly to the thalamus and directly to the cortex for activation of awake, desynchronized cortical EEG patterns.

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8
Q

What does cognition include?

A
  • thought processes
  • memory
  • perception
  • problem solving
  • emotion
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9
Q

What is the most important aspect of a neurological assessment?

A

Conscious state

  • deteriorates quickly and before any other neurological change is noted- often very subtle
  • Most common tool to asses it is GCS
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10
Q

List some reasons for loss of consciousness

A
  • Seizers
  • Fainting
  • Low blood pressure
  • Hypoglycaemia
  • Stroke
  • Overdose
  • Dehydration
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11
Q

Concerns that may indicate consciousness issues include…

A
  • pupillary changes
  • behavioural changes
  • limitations in movement
  • or alterations in sensation
  • GCS score falls 2+ points
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12
Q

List the acronym for the rapid score of consciousness

A 
AVPU 
A- alert 
V- responds to voice 
P- responds to pain 
U- unresponsive
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13
Q

GCS history

A

used as a way to consistently communicate about conscious state.
- Developed in 1974 in Glasgow

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14
Q

What ‘pain’ could you do to assess best motor response?

A

central pain
- trapezius squeeze

Peripheral pain

  • nail bed pressure
  • inter-phalangeal joint pain
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15
Q

What to look for in unusual pupils?

A
  • unsymmetrical in size
  • unsymmetrical in shape
  • uneven reaction
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16
Q

What is the allowed difference between pupillary sizes?

A

1mm

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17
Q

Causes of dilated pupils?

A
  • alcohol
  • atropine (anticholinergic medication)
  • some reactions to drugs
  • stress stress
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18
Q

Causes of constricted pupils?

A
  • opioid overdose
  • lower brain stem compression
  • damage to the pons
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19
Q

Changes in breathing patterns indicate what?

A

that a neurological injury may have occurred.

- changes in respiratory pattern assist in identifying the level of brain stem dysfunction or injury.

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20
Q

Describe Cheyne-strokes breathing

A

repeated episodes of apnea and hyperventilation

- bilateral cerebral lesions

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21
Q

Describe central neurogenic hyperventilation

A

deep and rapid breaths at a rate of at least 25 breaths per minute. Increasing irregularity of this respiratory rate generally is a sign that the patient will enter into coma.
- lesions on midbrain and upper pons

22
Q

Describe apneusis

A

by deep, gasping inspiration with a pause at full inspiration followed by a brief, insufficient release.
- lesions on lower to mid PONS

23
Q

Describe clustered breathing

A

clusters of breaths followed by apneic episodes of variable duration, typically caused by low pontine or high medullary lesions.
- lesions of lower pons and upper medulla

24
Q

Describe ataxic breathing

A

abnormal pattern of breathing characterized by complete irregularity of breathing, with irregular pauses and increasing periods of apnea. As the breathing pattern deteriorates, it merges with agonal respiration.
- lesions of the medulla

25
Q

Hypotension=

A

low blood pressure

- can be a signs of neurological deterioration in terminal event

26
Q

Hypertension=

A

high blood pressure

- common with inter-cranial injuries

27
Q

Dysrhythmias=

A

(also called an arrhythmia) is an abnormal rhythm of your heartbeat.
- occurs as a result of changes in intra-cranial pressure

28
Q

Tachypnoea=

A

abnormal breathing rate

- rapid respirations that are irregular in pattern

29
Q

Stroke types=

A

Ischaemic= block of oxygen to the brain

Hemorrhagic= bleeding

Transient ischaemic attack (TIA)= blockage that doesn’t last to long

stroke= lack of blood to the brain that may be interrupted by a clot or haemorrhage

30
Q

FAST acronym stands for…

A

Face
Arms
Speech
Time

31
Q

What is the opinion of pain perception

A

pain is what ever the experiencing person says it is, existing whenever he or she says it does.

32
Q

Source of pain- nociceptive pain

A

pain that usually acute and transmitted after noxious stimuli.

33
Q

Source of pain- cutaneous pain

A

superficial pain which originates from the nerves in the skin or subcutaneous tissue.

34
Q

Source of pain- somatic pain

A

deep pain in tendons, ligaments, nerves, bones and blood vessels.

35
Q

Source of pain- viceral pain

A

poorly locatised pain arising from body organs in the thorax, cranium and abdomen

36
Q

Characteristics of acute pain

A
  • sudden onset
  • short duration
  • mild to sever intensity
  • normal response to noxious stimuli and tissue injury
    e. g. surgical incision, burns and fractures
37
Q

Characteristics of chronic pain

A
  • constant pain
  • lasts 3 months in the last 6 months
  • can cause long lasting psychological consequences
    e. g. phantom limb pain, rheumatiod arthritis and stroke
38
Q

Complications of chronic pain

A
  • $$
  • psychological
  • interputs daily activity
  • drug abuse
39
Q

4 fundamental processes involved in nociception which makes an individual aware of pain

A
  • transduction
  • Transmission (movement of impulse from the site of origin to the brain)
  • Perception (developing conscious awareness of pain)
  • Modulation (the inhibition of pain impulse transmission and awareness)
40
Q
  • transduction
A

Changing nocious stimuli

  • tissue damage may occur due to inadequate blood supply
  • activate nociceptors and prepare their membranes for movement of electrical impulse
41
Q

Describe the transmission of pain

A
  • cutaneous nerve transmission travels through reflex arc.

- impulse travels to the brain at rate of 90 meters per second

42
Q

Define modulation

A

activation of descending neural pathways that inhibit transmission of pain to the brain.

43
Q

Characteristics of pain that are usually assessed are=

A
  • verbalisation and description of pain
  • duration and location of pain
  • frequency and intensity of the pain
  • type of pain
    alleviating factors
    physiological indicators of pain
  • behavioural responses
  • referred pain
44
Q

Pain assessment mnemonics

A 
PQRSTU 
Precipitating factors 
Quality/quantity 
Region/radiation 
Severity 
Timing/treatment 
Understanding patient perception
45
Q

Acute pain physical indicators

A 
• Elevated blood pressure
• Increased pulse rate
• High respiratory rate
· Pallor and perspiration
• Dilated pupils
• Characteristic pain
behavioural responses
46
Q

Chronic pain physical indicators

A 
• Normal blood pressure
and pulse rate
• Normal respiratory rate
and normal pupil size
• Loss of sleep and
enjoyment in life
· Depression and anxiety
• Trouble concentrating
and irritability
47
Q

Behavioural indicators- Facial expressions

A 
· Grimacing
• Clenched teeth
• Curled toes/fists
• Wrinkled forehead
• Tightly closed eyes
• Lip biting and nasal
flaring
48
Q

Behavioural indicators- Body movement

A 
Restlessness
Immobilisation
Muscle tension
Pacing activities
Rhythmic activities
Protection of injured body
parts
49
Q

Define referred pain

A

when pain is felt in an area other then the organ/issue

e,.g heart attack felt in neck

50
Q

Barriers for effective pain management

A
  • nur/mid beliefs and behaviours
  • prescribers
  • patient and family influences
  • cost
  • lack of access to analgesics and adjuvants
  • legal concerns
  • tolerance
  • physical dependence
  • addiction
  • nur/mid using pain as a diagnostic test

NUR1112- Nursing (11 decks)

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