Glasgow Coma Scale Assessment

Glasgow Coma Scale

• Utilized for baseline and ongoing assessments of consciousness.
• Evaluates eye, verbal, and motor responses.
• Scale ranges from 3 (no response) to 15 (full consciousness).

Motor Function Assessment

• Coordination: Client extends arms, alternating touch to nose; expected response: smooth movements.
• Gait: Assessed without client’s awareness; expected: smooth and coordinated walking.
• Balance:
  • Romberg Test: Stand with feet together, arms at sides, eyes closed for at least 5 seconds.
  • Heel-to-Toe Walk: Walking in a straight line without losing balance.
• Muscle Strength: Client pushes or pulls against resistance; expected: equal or stronger on dominant side.

Sensory Functions (Eyes Closed)

• Pain Sensation: Alternating sharp/dull objects; client reports sensations.
• Temperature: Identify warm/cold tubes.
• Light Touch: Cotton ball touches skin; client indicates contact.
• Vibration: Tuning fork; client reports sensation timing and location.
• Position: Reposition limbs; client identifies orientation (up/down).
• Discrimination:
  • Two-point discrimination: Measures minimal distance felt as two separate points.
  • Stereognosis: Identify familiar objects by touch.
  • Graphesthesia: Identify traced numbers on palm.

Aspiration Risk

• Assessment and precautions to prevent aspiration during care.

Heimlich Maneuver

• First-aid technique for conscious choking.
• Sharp upward thrusts below ribcage, 5 times; adjust for pregnant individuals by maneuvering above the sternum.
• Risks include potential injuries, bruising, or fractures.

Diaphragmatic Breathing

• Common in males and children; noticeable abdominal movement during deep breaths.

Breathing Sounds

• Expected:
  • Bronchial: High-pitched, hollow sounds; exhalation longer than inhalation.
  • Bronchovesicular: Medium-pitched; best heard between shoulders.
  • Vesicular: Low and soft; inhalation longer than exhalation.
• Unexpected/Adventitious:
  • Crackles: Bubbling sounds indicating fluid in the lungs; suggest pulmonary issues.
  • Wheezes: High-pitched sounds from narrowed airways; associated with asthma or COPD.
  • Rhonchi: Deep, snoring sound; indicates thick mucus; can usually be cleared by coughing.
  • Pleural Friction Rub: Dry sounds indicating irritation of pleura; associated with breathing difficulty.
  • Apylexis: Absence of breath sounds.

Cyanosis Assessment

• Light skin tones: bluish tint; darker tones: grayish skin in palms/soles; brown tones: yellowish.
• Indications of hypoxia or impaired venous return; commonly assessed at nail beds, lips, and mucous membranes.

Hypoxia Manifestations

• Early Signs:
  • Increased respiratory rate, heart rate; restlessness, anxiety.
  • Pale skin, elevated blood pressure, use of accessory muscles.
• Late Signs:
  • Stupor, cyanosis, low respiratory rate, bradycardia, hypotension.

Oxygen Saturation

• Pulse Oximeter: Non-invasive device measures oxygen levels at various body sites.

Indwelling Urinary Catheter Assessment and Care

• Size/type for insertion varies by patient demographics; allergies necessitate specific materials.
• Routine care should include cleansing and monitoring for patency and kinks.

Wound Healing and Pressure Injury Classification

• Stage 1: Non-blanchable erythema; discomfort.
• Stage 2: Partial thickness loss; might resemble blister.
• Stage 3: Full thickness skin loss; may expose subcutaneous fat.
• Stage 4: Extensive tissue loss; muscles and bones may be visible.
• Unstageable: Escar obscures true depth; may indicate serious risk factors.

Wound Dressing Types

• Woven Gauze: Absorbs exudate; used for moderate to heavy drainage.
• Non-adherent Dressings: Prevent pain on removal; designed to avoid sticking.
• Hydrocolloid: Forms a seal, maintains moisture; stays for several days.
• Hydrogel: Provides moisture for dry wounds; soothing.
• Alginates: Highly absorbent; ideal for draining wounds.

Care of Wound Infection

• Clean wounds from least to most contaminated; use isotonic solutions for cleansing.

• For irrigation, maintain pressure and use appropriate tools; monitor for infection signs.### Wound Complications: Dehiscence and Evisceration

• Dehiscence: Partial or total separation of a sutured wound, typically affecting underlying skin layers.

• Presents with visible wound edge separation and serous drainage.

• Patients may report a popping sensation and feeling as though the wound has given way.

• Immediate actions: Notify healthcare provider, stay with the patient, cover the wound with a blanket or pillow, and apply pressure if coughing occurs.

• Evisceration: Severe dehiscence where organs protrude through the wound.

• Requires immediate coverage of the wound with a sterile saline-soaked towel or dressing to prevent bacterial contamination.

• Keep essentials nearby to avoid unnecessary movement.

• Patient Positioning: Supine position with hips and knees bent reduces tension on the wound.

• Observation: Monitor for signs of shock such as pallor, clamminess, rapid heart rate, and hypotension. Maintain a calm environment and keep the patient NPO until surgery.

Stages of Wound Healing

• Inflammatory Stage: Lasts 3 to 6 days, focusing on controlling bleeding and delivering immune response elements.

• Features vasoconstriction, fibrin accumulation, and macrophage activity for phagocytosis.

• Prolonged inflammation can occur due to inadequate or excessive responses.

• Proliferative Stage: Lasts from 3 to 24 days, characterized by tissue replacement and granulation.

• Involves collagen formation, wound contraction, and resurfacing with new epithelial cells.

• Maturation Stage: Begins around day 21, with scar strengthening and normalization of appearance.

• The process may take over a year and depends on the wound's extent.

Wound Healing Processes

• Primary Intention: Minimal tissue loss, with edges approximated, healing rapidly and presenting low infection risk. Example includes closed surgical incisions.

• Secondary Intention: Involves significant tissue loss with unapproximated edges, longer healing times, and a higher infection risk. Example includes pressure injuries.

• Tertiary Intention: Characterized by deep, widely separated wounds that initially remain open for infection control. Closure occurs later, extending healing time.

Fall Risk Assessment

• Defined as an unintended descent to the ground, making it a leading cause of accidental injuries, especially among older adults.
• Risk factors include unassisted toileting, altered cognition, mobility issues, and environmental hazards.

Fall Prevention Strategies

• Conduct fall-risk assessments at admission and regular intervals.

• Educate clients on using call lights and demonstrate proper usage.

• Ensure call lights are accessible, and offer timely bathroom assistance.

• Maintain good room lighting and familiarization with the environment.

• Ensure accessibility to assistive devices and safety elements like non-skid footwear.

• Document any falls in incident reports to identify patterns and refine prevention strategies.

Crutch Walking Techniques

• 4 Point Gait: Alternates crutches and legs, providing stable support with three points on the ground.

• 3 Point Gait: Both crutches move forward together while swinging the unaffected leg ahead.

• 2 Point Gait: Moves one crutch with the opposite leg simultaneously, mimicking natural walking.

• Swing Through Gait: Involves swinging legs past crutches, requiring upper body strength for balance.

Other Mobility Considerations

• Utilize gait belts and various mobility assistance devices for safe ambulation.

Dosage Calculations

• Understand oral, parenteral, and injectable dosage calculations for effective medication management.

Tuberculin Test

• The PPD test is used for tuberculin testing, assessing for allergies or sensitivities to medications.