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Observations : NURSING PROBLEM - Assessing level of consciousness

The GlasgowComaScale(Figure 2.1), used in concurrence with vital signs, a patient is repeatedly used to appraise the level of perception. The scale uses three indicators of consciousness: eye opening, motor response and verbal response. A score is awarded for routine patients in each area.

Figure 2.1 Map of conscious level (copy of this kind is, the Royal Free Hospital NHS Trust). 

The level of consciousness can be assessed by a variety of methods. Explain to the patient, whether consciously or unconsciously, with frequent observations are needed, both during the day and night. It is generally believed that patients remain unaware of the voices, even if they cannot act in response, and if explanations are not specified, they can become anxious and sad. 

All comments must be included in the local documentation.

INTERVENTION: assess the level of awareness
Mr. Ellis assess the level of consciousness every few minutes.

•  A pen torch.
• Table Glasgow Coma Scale.
• Equipment for the assessment of vital signs, as detailed above.

Before the critical-evaluation of a patient of consciousness, other sub-carrier to try him for the prescription of sedation or conditions, paralysis, paraplegia, language barriers or degrees of deafness, because it affects its ability to respond.

Share price in the evaluation of the response reveals

This reaction is assessed against the following criteria:

"Open your eyes impulsively," open your eyes to the lack of stimulation of the observer, such as voice or touch. This can be seen from space. If the patient is unable to eye because of swelling, nerve palsy or the presence of a link must be documented eye gaping. If the eyes are open and not blinking shows, close your eyes and observe if they open of your own accord.

"Eyes open to oral stimuli: If no spontaneous eye opening, to converse with the patient and observe the reaction to begin the fight against the patient and greets him by name, without touching if no response, go to the woman for him ask .. eyes. If still no response, Raise Your Voice and repeat the instruction.

"Eyes open to pain": If no response to voice, touch the patient's hand or shoulder or shake. If it does not cause a reaction, a slight pressure on the trapezius (muscle at the base of the neck to the top of the shoulder) apply, rub the breastbone and apply a light pressure on the superciliary region. This technique and others are discussed in more detail (page 38, see also Lowry, 1998).

See instructions for "pain response" on the testing of patient response to pain. This procedure must be used with caution to avoid injury.

No: the patient to open his eyes. This may indicate a lesion of the oculomotor nerve or brain stem.

Procedure for assessing verbal response

Thіs response assessed according to tο thе Following criteria:

"Makes the thoughtful discourse: if the patient can be accurate describe the details of time, the person and the place where he is said to have directed (Jennett and Teasdale, 1974; Auck and Crawford, 1998).

"Is this confusing the speech at this level the patient's ability to sentences (it can be a good attention span and be able to participate in a conversation) form, but is unable to questions that show that it is oriented to meet time, place or person (Auck and Crawford, 1998).

"The inappropriate words: This category may be appropriate if the patient cannot speak, if there is a tendency to words rather than sentences, when the answers are coming to the painful stimulus following, where the words or phrases that are repeated or when there a steady loss of attention.

A patient whose first language is not English may return to his mother seem so confused. An interpreter may be of assistance.

"Incomprehensible sounds ": the patient is responding to stimuli or spontaneously sounds instead of words used.

None: no sounds at all are made independent of the stimuli. If this is due to the presence of an endotracheal tube or tracheostomy should be noted.

Procedure tο assess motor response

Thіs response іs assessed according tο thе following criteria:

Used painful stimulus highly contentious when determining a patient’s neurological status should only be used wіth great caution (Lowry 1998).

‘Obeys commands’: thе patient іs able tο Obey simple commands, such as ‘Lift up your right arm’.

‘Localizes tο pain’:If thе patient іs unable tο Obey simple commands, a central pain stimulus should be applied briefly localizing tο Pain tο Occur a patient raises hіs hand tο slightest chin level when thе Painful stimulus above a level, e.g. trapezius pinch or supraorbital ridge pressure, or when he tries tο Remove a distressful stimulus.

Suggested techniques for applying central painful stimuli аre:

Peak pressure eyebrows by placing the hand on the forehead of the patient, using the palm of thumb on the supraorbital point (the lean ridge on the apex of the eye). Steadily increase the pressure until a response or a maximum pressure. Do not apply pressure or prolonged use today because it could lead to tissue damage. This site may be used as an injury or orbital facial fracture or skull are present (Lowry, 1998, Shah, 1999) pinch of Keystone: bare shoulder and gently squeezing the trapezius muscle. This muscle is located at the base of the neck, shoulder. Gradually increase the pressure until a response is generated or the maximum pressure. Do not apply pressure or use extended several times, as this can cause tissue damage at the end (Lowry, 1998, Shah 1999).

Rub the sternum or by applying pressure to the nail bed is not recommended as it may cause permanent damage to tissues (Lowry, 1998) the cause.

Normal flexion to pain "turns up arms at the elbows, wrists, without rotation, in response to pain (Figure 2.2.1) (Shah, 1999).

"Abnormal flexion to pain" fold out the arms from the elbows, wrist's bent posture due to spasticity, the pain response (Figure 2.2.2) (Shah, 1999).

"Extends to pain" extending the arms at the elbows, withdrawal, after painful stimulus (Figure 2.2.3) (Shah, 1999).

"No comment" No response is observed after the application of painful stimuli.

Pupillary size and reaction procedure to assess

 "Abnormal flexion to pain" fold out the arms from the elbows, wrist's bent posture due to spasticity, the pain response (Figure 2.2.2) (Shah, 1999).

"Extends to pain" extending the arms at the elbows, withdrawal, after painful stimulus (Figure 2.2.3) (Shah, 1999).If intra-cranial pressure іs rising within thе skull, thе Optic nerve may be compressed, interfering wіth thе pupil’s normal reaction tο light.

To assess the size of the pupil of the patient, observing the size of each student. Refer to map patterns of observation and write the correct format for each eye. This observation should be made before the light is applied directly to the eyes (see below).

To evaluate the response of students, dim the lights in the room, the patient gradually eyelid open and light the torch of the pupil of patient and further than, look right for a change in pupil size ( Lowry, 1998) repeat on the other eye. Record of each student something strong, slow to respond to the observation grid by local documentation.

Procedure for motor function / branch to assess the movement of the upper end for the conscious patient, the patient holds the hands one after the other and asks him to get away, or you pull him, as you apply some resistance. Assess the strength and equality movement to determine whether each side is lower than the other. Document your observations using the categories in Table 2.2

For the unconscious patient's previous responses to hurting stimuli should be documented (see Table 2.2).

Procedure for motor function / branch to assess the movement of the lower

For the conscious patient, rather than resistance to the knees of the patient and him on his knees to ask. Assess the strength and equality movement. Record your observations using the categories listed in Table 2.2. For the unconscious patient's previous responses to pain are recorded (see Table 2.2). Record your observations using the categories below. You'll find that on the Observation, Chart(Figure2.1) spastic flexion is not integrated in the listing to the legs, because the bending of the leg pain is a regular reaction. In a spontaneous movement of the extremities in an unconscious patient should be observed, although not in response to be external stimuli.

Vital Signs
It is important that the patient's temperature, blood pressure, pulse and respiration are also included because changes in vital signs may indicate a compression or damage in the brain stem.

The quality is the good practice enterologic-TIP! Nurse of the transfer is made by the nurse for a number of comments the nurse present at the following CAL consistency of results for the transfer.

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