Glasgow Coma Scale Assessment

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Questions and Answers

What is the primary risk associated with administering enemas to older adults and pregnant women?

Increased risk of hyperkalemia

Development of colorectal cancer

Electrolyte imbalance and intestinal mucosa damage (correct)

Infection at the administration site

What makes normal saline enema the safest choice for infants and children?

It is isotonic and equal to the osmotic gradient (correct)

It has a high volume which encourages bowel movement

It has a medicinal effect on the intestinal lining

It draws excess fluid into the colon

Which type of enema should not be used for infants or dehydrated patients?

Medicated enema

Oil retention enema

Low-volume / hypertonic enema (correct)

Normal saline enema

In which position should a patient typically be placed for a cleansing enema?

Left side in Sims position with right leg flexed Signup and view all the answers

What is the recommended length of time a patient should retain a medicated enema for optimal effect?

1 to 2 hours Signup and view all the answers

What is the characteristic appearance of sanguineous exudate?

Bright red and fresh Signup and view all the answers

What type of exudate is indicative of infection in a wound?

Purulent Signup and view all the answers

When cleansing a clean surgical wound, how should the process be conducted?

With gentle friction from the incision to the surrounding skin Signup and view all the answers

What is the recommended pressure for irrigating a deep wound?

5 to 8 psi Signup and view all the answers

Which solution is NOT recommended for wound cleansing?

Distilled water Signup and view all the answers

What is the appropriate technique for irrigation of a wound?

Applying continuous pressure with a piston syringe Signup and view all the answers

How should sutures and staples be managed during wound care?

They should be removed when deemed necessary by a provider Signup and view all the answers

What outcomes indicate the effectiveness of administering antimicrobials in wound care?

Decreased white blood cell count and increased comfort Signup and view all the answers

What is the highest value on the Glasgow Coma Scale indicating full consciousness?

15 Signup and view all the answers

What does the Romberg Test assess?

Balance Signup and view all the answers

Which sensory function test involves asking a client to identify an object placed in their hand?

Stereognosis Signup and view all the answers

What is the primary technique used in the Heimlich maneuver?

Inward and upward thrusts to the abdomen Signup and view all the answers

Which of the following describes bronchial breathing sounds?

Loud, hollow sound, high pitch Signup and view all the answers

What sign indicates early manifestations of hypoxia?

Restlessness and tachycardia Signup and view all the answers

Which condition could cause a pleural friction rub sound?

Pulmonary embolism Signup and view all the answers

What should be observed during the coordination assessment of motor function?

Client extending arms and touching their nose Signup and view all the answers

Where can cyanosis be assessed in darker skin tones?

Soles and palms Signup and view all the answers

What indicates bradypnea as a manifestation of hypoxia?

Decreased respiratory rate Signup and view all the answers

What does the pulse oximeter measure?

Oxygen saturation Signup and view all the answers

Which abdominal injury is a risk when performing the Heimlich maneuver?

Bruising of the stomach Signup and view all the answers

What sound is produced by air moving through thick mucus fluid?

Rhonchi Signup and view all the answers

In which breathing pattern does exhaling last longer than inhaling?

Bronchial Signup and view all the answers

What characterizes dehiscence in a wound?

Partial or total separation of a sutured wound Signup and view all the answers

What action should be taken immediately if a patient experiences evisceration?

Cover the wound with a sterile saline soaked towel Signup and view all the answers

During which stage of wound healing does scar strengthening occur?

Maturation or Remodeling Stage Signup and view all the answers

What is the primary characteristic of healing by primary intention?

Little or no tissue loss with edges approximated Signup and view all the answers

Which of the following is a risk factor for falls in older adults?

Altered cognition, such as dementia Signup and view all the answers

What is a key preventive strategy for falls among patients?

Educate clients on using the call light Signup and view all the answers

What type of gait involves swinging both legs past the crutches?

Swing-through gait Signup and view all the answers

What does the inflammatory stage of wound healing typically last?

3 to 6 days Signup and view all the answers

What is the major concern during the fall risk assessment for elderly patients?

Identifying and documenting patterns of falls Signup and view all the answers

What is a common outcome of healing by secondary intention?

Increased risk of infection and scarring Signup and view all the answers

What is the required positioning of the patient experiencing evisceration?

Supine with hips and knees bent Signup and view all the answers

Which of the following best describes tertiary intention healing?

Closure occurs when free of infection and edema Signup and view all the answers

What emotional state should be maintained for a patient at risk of shock?

Calmness Signup and view all the answers

What does the presence of heaves indicate in a patient?

Possible heart failure Signup and view all the answers

Which of the following heart sounds indicates the closure of the aortic and pulmonic valves?

S2 Signup and view all the answers

Where is the apical pulse most accurately located?

Mid left clavicular line in the 4th or 5th intercostal space Signup and view all the answers

What is an indication of S3 heart sound?

Heart filling too fast Signup and view all the answers

What characterizes a stage 2 pressure injury?

Partial thickness skin loss with exposed dermis Signup and view all the answers

What should be used during a straight catheter insertion for a patient with a latex allergy?

Silicone or Teflon catheter Signup and view all the answers

Which dressing is most appropriate for maintaining a moist healing environment for a stage 2 pressure injury?

Hydrocolloid dressing Signup and view all the answers

What is a common characteristic of skin in stage 1 pressure injuries?

Non-blanchable erythema of intact skin Signup and view all the answers

What type of sound does a thrill resemble when felt at the heart?

Vibration like a purring kitten Signup and view all the answers

Which type of wound dressing is utilized for mechanical debridement?

Damp to damp dressing Signup and view all the answers

Which finding indicates potential right-sided heart failure?

Distended right jugular vein Signup and view all the answers

What does the Braden scale measure?

Risk of skin breakdown Signup and view all the answers

What type of drainage is characterized by clear and watery fluid, often seen in the early healing process?

Serous drainage Signup and view all the answers

Study Notes

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.

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Description

Test your knowledge on the Glasgow Coma Scale and its application in assessing a client's level of consciousness. This quiz covers the scale's components, including eye, verbal, and motor responses, as well as understanding the scoring system from 3 to 15.