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Nursing 1160A/B Final: Review 1180

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Nursing 1160A/B
Karen Ferguson

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Review 1180 Mental Status—Week 1 What comprises a mental status?  ABCT + MMSE/MiniCog: Appearance, behaviour, cognitive function, thought process o Behaviour: eye contact, speech, facial expressions o Cognitive function: orientation, attention span, memory, judgment (safety concerns) o Thought process: understandable, logical and rational, coherent, relevant The Faces of the 3 D’s:  Dementia: slow, subtle process resulting in progressive loss of cognitive function  Depression: chemical imbalance enhanced by psychosocial factors  Delirium: ACUTE confusion Neurological Assessment: Week 2 So important because: TBI (traumatic brain injury) Health promotion:  FAST (how to spot a stroke) o Face dropping, arm weakness, speech difficulty, time to call 911 Components: 1. Vital signs: increasing pulse/pressure= concern 2. Pupillary response: PERRLA (cranial nerve 3) 3. LOC (alert, drowsy, stuporous, unresponsive) 4. Speech (cranial nerve 9, 10) 5. Facial weakness (cranial nerve 7) 6. Pronator drift (motor function) 7. Proximal limb weakness (motor function) 8. Overall cognitive function 9. Common reflexes?? Glasgow Coma Scale: LOC (8 OR LESS):  Speak, shout, shake, pain  Spontaneous: enter the room and pt. wakes up  Usual voice: state pt. name and ask him or her to open her eyes  Loud voice: only if no response to usual voice  Tactile: touch pt. shoulder or arm LIGHTLY  Noxious stimulation (pain): nail pressure BUT TELL PT FIRST Respiratory Assessment: Week 3 Lifespan considerations:  Pregnant women: not rate, but effort  Infants and children: apgar scoring above 6pts.  Older adults  Cultural considerations: no difference racially, but size matters Involves:  Diffusion and perfusion o Indirectly by SpO2 monitor o 92-100% is expected o Directly by arterial blood gases—directly from artery o 95%-100% expected  Ventilation by rate, rhythm, depth, and effort  Hemoglobin o Women= 115-160 [PERIODS] o Men= 135-170 [TESTOSTERONE] Assessment: The Interview:  Involves basic questions (i.e. health history)  INCLUDES HEALTH PROMOTION (smoking cessation plan, seasonal vaccinations) Assessment: Physical Exam: IPPA:  Inspection: cyanosis, symmetry  Palpation: bumps, bruises, rashes, expansion, hardness  Percussion: not used very often, but looking for RESONANCE  Auscultation: breath sounds Breath Sounds:  Bronchial: high pitch, harsh/hollow o Short during inspiration, long during expiration o Trachea and larynx  Bronchovesicular: moderate pitch, blowing o Inspiration= expiration o Major bronchi/sternum  Vesicular: expected finding, low pitch, breezy o Long inspiration, short expiration o Peripheral lung fields  Adventitious: crackles, pleural friction rub, wheeze Peripheral Vascular Assessment: Week 4 Is the blood flowing? Assessment: CMSTBEP (EVERYTHING DONE ON BOTH SIDES!!)  Colour: pink, warm, moist  Movement: movement the limbs distal to the injury  Sensation: distal to the injury  Temperature: use dorsum of hand distal to injury  Blanching: cap refill  Edema: swelling, fluid in interstitial space  Pulse: distal to injury Arterial vs. venous insufficiency: Arterial:  Paler raised, duskier lowered  Cooler temp (decreased blood flow)  Decreased or absent pulse  Absent or mild edema  Thin, shiny skin, decreased hair growth, thickened nails Venous:  Consistent colour  Temp is consistent  Pulse is palpable (unless edema)  Edema is present and can be severe  Brown discolouration around ankles GI Assessment: Week 5 Assessment: IAP  Subjective data  Examine samples  Inspection: oral cavity (mucous membranes) and trunk (flat, hair growth, symmetry, striations, movements)  Auscultation: RLQ, RUQ, LUQ, LLQ o Optimal time: before first meal (borborygmi) o Bruits over arterial v
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