Assessing cognitive function objectively
Level of consciousness: oriented x 3, alert
Behaviour and appearance: reveal info about mental status, can understand speech and context
Language: voice, reflection, tone, manner of speech are answered
Intellectual function: can they count? Memory, knowledge, thoughts, ideas, association, and judgement
Assessing cognitive function subjectively
Common concerns or injuries (I.e brain injuries, periods of confusion and forgetfulness)
Past health history: has this happened before? Either personal or family history (I.e dementia)
Lifestyle: diet, exercise, stress,
Age related changes
Describe normal sensory function
-patient with normal sensory function will respond to all stimuli that is being tested with adequate reception, perception, and reaction are all present
Ex. Alert, can remember what you just asked them, oriented x3, normal reflexes
What are some issues or concerns related to cognitive function?
Disorientation (inability to recognize 1 or more of orientation x 3)
- cause for concern because of SAFETY
Nursing interventions to promote safety with cognitive concerns
Physical environment
- making sure bed is low to the ground
- no clutter on the ground
- personal belongings of patient on their nightstand within reach
- making sure call bell is within reach
- bed alarms
- wander guards
- control lights and noise (day and night)
- anticipating restroom needs
Personal life history
- who was/is this person before cognitive impairment?
- draw on their prior hobbies or interest
- avoid prior fears and dislikes
List and describe the subjective and objective aspects of assessing altered sensory function
Subjective:
- common concerns or injuries: visual or hearing alterations, any accidents that might impair sensory function
- past health history: person and family, hereditary diseases
- lifestyle: things that influence your sensory function health, eating carrots for ex. Is good for the eye
- age related concerns: as people grow older their vision decreases, wearing reading glasses as you age
Objective
-environment: are there hearing aids at the bedside? Crutches around? Reading glasses
- vision assessment: do they read newspaper ? Books at the bedside, do they have good coordination, do they squint
-hearing assessment: do they tilt their head towards you, do they need you to speak louder or repeat what you said, do they speak louder
Tactile assessment :picking up things without dropping, fine motor skills
Describe the comprehensive pain assessment
superficial pain (body surface) using broken tongue depressor, using light touch can be done with cotton ball, checking for hot and cold (epidural)
ALWAYS COMPARE FINDINGS side to side of body, and before and after (what the broken tongue depressor felt like with eyes open vs. Eyes closed)
What is the physiology of pain?
Body’s response to ‘pain’ can be thru the sympathetic and parasympathetic nervous response
Sympathetic: increased heart rate, respiratory rate, elevated blood pressure, dilated pupils, client may appear restless and anxious
Parasympathetic: vital signs may appear normal due to adaptation, dry warm skin, client may appear depressed or withdrawn
How does acute and chronic pain influence physiologic, social, spiritual, psychological, and cultural factors
Acute pain:
Physiologic: breathing fast, pale skin, increased heart rate
Psychologically: can experience fear, anxiety,
Socially: eliminate social interactions with close ones, who they come into contact with
Spiritually: they may question their faith
Chronic pain
Physiologic: vital signs may appear adapted, slower heart rate
Social: decreased interaction with their social environment and physical environment
Spiritual: no desire to engage in spiritual activity, question meaning of pain, or their life purpose
Psychological: depression, difficulty sleeping, change in eating patterns, limit daily activity
Describe pain assessment
SUBJECTIVELY:
Can use COLDSPAA
OBJECTIVELY:
Non verbal behaviour, slight tremors? Pale skin? Avoids being touch? Occasionally winces ?
What are some nursing interventions to relieve pain?
- collaboration
- remove stimulus
- reposition patient if needed
- guided imagery
- progressive relaxation
- distraction
- massage
- bandage support
- breathing techniques
Pain management is high priority
What is the function of sleep?
- physiological restoration, cellular metabolism, allows for energy to be conserved for day time, heart rate decreased, protein synthesis, lower BMR
- psychological restoration, increased blood flow to brain, increased oxygen consumption while we are sleeping, epinephrine is released for memory storage throughout the day when they’re awake
What influences sleep?
Circadian rhythm: regulates biological functions. Light, temperature, social activities, and work routine affect circadian rhythms and daily sleep -wake cycles.
Age as we grow older, we don’t need as much sleep
List and describe the stages of sleep:
- NREM: light sleep lasts for a few minutes.
- NREM: sound sleep lasts between 10-20 mins
- NREM:deeper sleep lasts 15-30 mins, vital signs appear to be lower
- NREM: deepest sleep lasts 15 mins at a time, vital signs lower, sleep walking can occur
- REM = vivid dreaming lasts 15 mins on average heart rate and respiratory rate appear to be regular
Describe sleep assessment
subjectively: common concerns, past health history (is there insomnia that run in the family?), lifestyle ( do you have a bedtime routine?, do you drink coffee or energy drinks around evening?), age related changes (not needing as much sleep as you age)
What are some nursing intervention to promote sleep ?
Environmental control (make sure there isn’t too much light, noise, room isn’t too cold) Promote routine (consistent time that patient goes to sleep) Promote comfort (pain relief before bed, is bed clean and wrinkle free, empty bladder before bed, do they need more blankets or pillows?) Stress reduction (having conversations before they go to bed, journaling ?) Bedtime snacks Positioning (comfortable lying positions from module 10)
Do we need to minimize naps or sleeps during the day or at night ?
What are some factors that influence sleep that could occur?
Excessive day time sleep
Hyper-somnolence: abruptly falling asleep during daytime
Insomnia: problems falling asleep
Narcolepsy: neurological sleep disorder, feeling overwhelming sense of sleepiness
Parasomnia: undesirable sleep that occurs while sleeping
Shift work sleep disorder: occurs when sleep schedule does not align with circadian rhythm
Sleep apnea: people stop breathing for 10 seconds while asleep
Sleep deprivation: insufficient amount of restorative sleep
