N222: Assessments; cognitive, neurological and pain

what is the stupor or semi-coma LOC assessment meaning?

Unconscious, has motor response i.e. pulls away from painful stimulus. Otherwise groans, mumbles or moves restlessly.

what is the palpation inspection technique?

Use of touch to gather information using different parts of hands to detect different characteristics.

What does assessment mean?

a deliberate and systematic collection of information about a patient to determine the patient's current, past health, functional status and the patient's present and past coping patterns.

what do you do when the pain level is greater then 7

assess the Q and R --Quality (Q) Ask "How would you describe your pain?* --Region or Radiation Ask "Show me where you hurt. Does it stay there or does it spread somewhere else?* --Then immediately report the QRS of pain to your nurse or clinical instructor.

what does objective and subjective data form together?

database

what does functional status mean in assessment?

looking to see if the patient is still able to take care for themselves with there diagnosis/ disease

what do we do with the data we collect from patients?

makes a clinical judgment or nursing diagnoses about the individual's health state, response to actual or potential health problems, and life processes. from this we can create a plan of care to address identified needs and goals

what is the inspection technique?

"Concentrated Watching" where nurses look, listen and smell to distinguish normal from abnormal.

how do you begin a pain assessment?

"I'm curious whether you are bothered by pain right now."

What is objective data?

(sign), What the healthcare provider observes and measure on their own such as temperature, x-rays, Laboratory and physical data

what is subjective data

(symptoms), data that only the subject or "patient" can feel and will tell you. How they are feeling inside, pain, ictynes and is figured out from the health history

what happens during accommodation?

-- with focus on a distant object pupils dilate and with focus on a near object pupils constrict

name the chronic pain behaviors?

---Persistent pain behaviors with experience for months and years. Adaptation occurs over time. §Shows more variability. Higher risk for under detection and it's associated behaviors include bracing, rubbing Diminished activity Sighing and Change in appetite

what do the number represent in the numeric rating scale?

--1 to 3, mild pain --4 to 6, moderate pain --7 to 10, severe pain

what do you do when the pain level is between 1 and 6

--Assess PQRTU mnemonic --And ask, "At what level would you like your pain to be when you're moving around?" --Report to your nurse or clinical faculty your patient's response to this question AND the number they currently rate their pain.

what does pain look like in older adults?

--Not an inevitable part of aging --Serious impairment accompanies pain --Observe for changes in functional behavior

what are the key elements of cognition

--Orientation (awareness of time & location) --Registration (ability to repeat named prompts) --Attention & Calculation (ability to count and spell backwards) --Recall (ability to remember objects named earlier) --Language (ability to follow a series of spoken or written instructions)

what does the PQRSTU stand for?

--Provocation/Palliation (P): --What makes the pain worse and palliation is what makes the pain better --Quality (Q) §How does the pain feel, is it burning etc §Region or Radiation (R) --Region(R): where does it hurt --Radiation(R): does this pain spread somewhere else --Severity Scale (S): How much pain ex from 1-10 ---Timing (T): §How long and when does the pain occur --You (U) (meaning the patient: Understand/Unable to do) --What the patient is not able to do

explain and name the types of assessments?

--Review of the clinical record --health history --physical examination(head-to-toe) --functional assessment --risk assessment --subjective data --objective(sign) data

What is the mini-cog test?

--Screens for cognitive impairment in otherwise healthy older adults --Used with various language, culture, and literacy levels --takes 3 to 5 minutes to administer ---Consists of a 3-item recall test and a clock drawing test (CDT)

What is acute pain?

--Short term (< 6 months) --Identifiable cause --Self limiting --Self-protective

what does the pain assessment in older adult with cognitive impairments entail?

--Use Numeric Rating Scale or Verbal Descriptor Scale

how do you proceed a pain assessment?

--Using the PQRSTU mnemonic, begin by assessing the (S) Severity of your patient's pain. §To do this, you'll need to use a pain scale §In this class, you'll learn 3 pain scales 1. Numeric Rating Scale 2. Verbal Descriptor Scale 3. Faces Pain Scale Revised

what do you do when a patient cannot verbally communicate pain?

--can (to a limited extent) identify pain using behavioral cues. --Recall that individuals react to painful stimuli with a wide variety of behaviors.

what are the sound characteristics with auscultation inspection technique?

--frequency: the number of sound wave that we hear when were listening to the sound> --Loudness --quality: what does it sound like --duration: how long does the sound last

what must are nurses ensuring and looking for during inspection technique?

--identify degree of distress --Provide comfortable, private conditions --Provide adequate lighting and exposure --Inspect each area for size, shape, color, symmetry, position, abnormalities

name the acute pain behaviors

--involve autonomic responses --Protective purpose §Individuals experiencing moderate to intense levels of pain may exhibit the following behaviors: --Guarding, grimacing --vocalizations such as moaning, agitation, restlessness, stillness ---Diaphoresis: sweating Change in vital signs

What is chronic pain?

--last 6 months or longer --Malignant vs nonmalignant

what is the assessment if the patient is not alert?

1. name called in normal tone of voice 2. name called in loud voice -3. light touch on person's arm 4. vigorous shake of shoulder 5. pain applied Notice the stimulus used and the person's response to it.

what are the assess of motor function?

1.Cranial Nerve VII( facial nerve): lift eyebrows, frown, bare teeth 2.Upper extremity strength: hand grasps 3.Lower extremity strength: push one foot at a time against your palms one at a time

what does it mean for a patient to be alert?

1.eyes open at your approach or spontaneously 2.is oriented to person, place, and time 3.can follow verbal commands appropriately

What is pain ?

An unpleasant, subjective sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage".

What does consciousness refer to?

Being aware of one's own existence, feelings, and thoughts and of the environment.

what is the coma LOC assessment meaning?

Completely unconscious, no response to pain or any other stimulus. Light coma, some motor response, deep coma, no motor response.

what must the nurse ensure when using the palpation inspection technique?

Hands should be warm, fingernails short. must be slow, gentle, and systematic. making sure to start with light palpation by looking for superficially skin treasure, temperature, moisture and leave tender areas last looking for organ size

what is the auscultation inspection technique?

Listening to sounds of lungs, heart, blood vessels, & abdominal viscera

what do the score mean in the the mini-mental state examination(MMSE)

Maximum score is 30; 23-30=normal 19-23 borderline; 19=impaired.

what is the obtunded LOC assessment meaning?

Mostly sleeps, difficult to wake, acts confused when awake, converses in monosyllables, speech mumbled, requires constant stimulation to stay awake.

what is direct light reflex?

Normally, constriction of the same-sided

what is the lethargic or somnolent LOC assessment meaning?

Not fully alert, drifts off to sleep when not stimulated, drowsy, responds to questions/commands, thinking slow, fuzzy, inattentive, loses train of thought, spontaneous movement decreased.

what is the cognitive assessment?

Pertain to the psychosocial, emotional, cultural, and spiritual components of the patient

what is the assessment of pupillary light reflex?

Size, 3-5mm - Symmetry, equal - Shape, round - Response to light, brisk bilateral

what is the definition of orientation in cognitive assessment?

The ability to comprehend and to adjust oneself with regard to person, place, and time.

What does accommodation mean?

The adaptation of the eye for near vision

What does PAINAD stand for?

pain assessment in advanced dementia

What does PERRLA stand for?

pupils equal, round, reactive to light and accommodation

what is consensual light reflex?

simultaneous constriction of the other pupil

What is the percussion inspection technique and what does it detect?

tap body with fingertips to produce a vibration in the underlying organs which help determine location, size, and density of structures of the organs.

what is the difference between the bell and the diaphragm of the stethoscope?

the bell is used for low frequencies sound and the diaphragm used for high frequency sounds

what does is the assessment for older adults look like?

their sensory and physical limitations may affect ability to respond quickly - be patient; adjust pace of assessment data gathering to accommodate and their signs and symptoms tend to be settle compared to a normal person and compared to the disease they currently have.

what is the purpose for motor function assessment?

to check voluntary movement by giving the person specific commands because the movement requires transmission of a message from the cerebral cortex to the appropriate muscle on the opposite side of the body.

What does anisocytosis mean?

when one purples size is bigger then the other and it can only be 1mL or less difference and they should still be able to react to light then that would be normal

what does the PERRL mnemonic stand for

§ Pupils § Equal § Round § React to Light