Lab 1 slides Flashcards
(20 cards)
What are the objectives after Lab 1 in medical nursing?
Can perform a brief neurological assessment for the patient
Can check the patient’s blood glucose
Can position the stroke patient
Can support the patient’s breathing
Can administer oxygen therapy with a nasal cannula and oxygen mask
Can administer inhaled medicines by using a nebulizer
Can suction mucus from the patient’s airways (mouth and throat) patient safely
Can wear protective gear when treating patients with infectious diseases
What is suppea neurologinen status?
The purpose is to examine the function of the brain and nerves.
This is done at regular intervals and whenever there is a change in the patient’s condition.
What is checked in a brief neurological assessment?
- Anamnesis -
- Vital signs ABCDE -
- Blood sugar level -
- Extremity strengths, motor functioning, coordination -
- Symmetry/asymmetry of the face -
- Verbal response
- Stiffness of the neck
- Pupils
What is checked in the Glasgow coma scale (GCS) ?
The higher the score the better function and GCS of patient.
Eye response (you can score, 4 total points):
1 - No response
2- Pain (if they respond to paid)
3 - Voice/ verbal command (open eyes, acknowledge your voice)
4 - Normal Response
Verbal response (5 total points):
1 - No response
2 - Make incomprehensible sounds (not words just sounds)
3 - Able to make worlds but they aren’t appropriate (not sentences just words e.g dog, cat ball)
4 - disoriented sentences (put words together but its not making sense but they are still making phrases)
5 - Normal response, oriented sentences (full conversation)
Motor scale (6 total points):
1 - No response
2 - Abnormal extension (extension)
3 - Abnormal flexion (bending)
4 - Withdrawing to stimulus
5 - localized pain response
6 - Normal response
Add these together to get the right answer, the higher the better.
https://youtu.be/zbBqrmpSOqY?si=o0njEUBKhnCXotaF
What is flexion?
a bending movement around a joint in a limb (such as the knee or elbow) that decreases the angle between the body parts or the bones of the limb at the joint.
decrease the angle between two structures as they bend or move close together
What is extension?
Increase the angle between two structures as they straighten or move further apart
What is AVPU?
A = ALERT: is the patient alert?
V = VOICE: do you have to raise your voice to get a response from the patient?
P = PAIN: Does the patient only respond to a pain stimulus?
U = UNRESPONSIVE: Is the patient completely unresponsive?
Only the alert state is normal.
What is hemiplegia?
Hemiplegia is paralysis that affects only one side of your body. Hemiplegia affects either the right or left side of your body. It happens because of brain or spinal cord injuries and conditions. Depending on the cause, hemiplegia can be temporary or permanent. Some causes of hemiplegia are treatable or even reversible with immediate medical care.
Hemiplegia is paralysis, which means you can’t move or control the muscles in the affected body part. That can cause muscles that are completely limp. It can also cause spastic hemiplegia, a type of paralysis where muscles contract uncontrollably.
Hemiplegia affects either the right side of your body (right hemiplegia) or the left side of your body (left hemiplegia), with your spine (backbone) being the dividing line between the two halves.
What side of the body does a stroke affect?
After a stroke, the side of the body opposite to the affected side of the brain is usually impacted. A stroke on the left side of the brain typically affects the right side of the body, while a stroke on the right side of the brain typically affects the left side.
Care needs for left side hemiplegia?
Assistance with mobility and prevention of
complications like pressure ulcers.
Can also have joint stiffness
Goals of care of patient with left side paralysis or right side
Prevent and care for pressure ulcers if any.
Promote safe mobilization within limits of his condition.
Assessment of skin using Braden Scale for pressure ulcer risk assessment,
Also regular skin checks.
Nursing interventions for left side paralysis. Hemiplgia.
Turn Esko every two hours
to prevent pressure sores.
Use pillows for support
and maintain proper body
alignment.
Physiotherapy referral for
passive range-of-motion
exercises.
Encourage Esko to sit
upright, when possible, to
enhance circulation.
Care needs, goals of care for patient with aphasia, assessment too, nursing intervention
Care needs
Encourage communication
and understanding with the
help of aids if required.
Goals of care
Facilitate effective
communication with
healthcare staff and family.
Assessment
Stroke Aphasia Quality of
Life Scale (SAQOL-39).
Nursing interventions
Use simple, clear
instructions with visual
aids.
Use communication
boards or assistive
technology for speech.
Ask a speech therapist for
further assessment and
intervention.
What to check for or do when monitoring breathing?
Respiratory rate (hengitysfrekvenssi, hengitystiheys)
- Normal rate for adults is 12 – 16 times/a minute
- Breathing style (hengitystapa): movements (hengitysliikkeet), the use of accessory muscles of breathing (apuhengityslihakset)
Rhythm (rytmi) and depth (syvyys)
Breathing sounds (hengitysäänet)
The quantity and quality of respiratory secretions (hengitystie-eritteiden määrä ja laatu)
When is there a need for supplemental oxygen?
There is a need for supplemental oxygen when the patient has:
Respiratory failure (hengitysvajaus)
Oxygen saturation levels (happisaturaatio) drop under the normal values (<90-95 %)
The administration of oxygen is giving medical gas to the patient, so there must always
be a clear indication, order, and instructions from the doctor.
What are the characteristics of a patient in hypoventilation? What is the patient like?
Anxious, restless, confused, level of consciousness is lowered
Skin, mucous membranes, and nails are cyanotic
Pulse is rapid and weak (thread-like)
Accessory muscles of breathing are in use
What is hypoventilation?
Hypoventilation is breathing that is too shallow or too slow to meet the needs of the body. If a person hypoventilates, the body’s carbon dioxide level rises. This causes a buildup of acid and too little oxygen in the blood.
What is the purpose of suctioning of respiratoty secretions?
The purpose is to secure gas exchange when the patient has excess respiratory secretions or the patient has aspirated and can’t remove extra mucus from the respiratory tract.
What are the indications for suctioning of respiratory secretions?
Dyspnea
Bubbling or rattling breath sounds
Poor skin color (pallor, duskiness, cyanosis)
Restlessness, tachycardia, decreased oxygen saturation
What is required when suctioning of respiratory secretions?
Requires good aseptic technique and clinical judgment:
A risk for infections
Irritates mucous membranes
Can increase secretions if performed too frequently
Can cause oxygen saturation to drop further
Can put the patient in bronchospasm
Headinjury: ICP increases
Sputum samples can take out with the suctioning catheter if it is not otherwise possible.
