Nursing Assignmengt ON Sensorium PDF

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Complete Assignment on nursing sensorium ...

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NURSING ASSIGNMENGT ON SENSORIUM SENSORIUM (UNCONSCIOUSNESS): ASSESSMENT AND MANAGEMENT DEFINITION: Sensorium is the totality of those parts of the brain that receive process and interpret sensory stimuli . The sensorium is the supposed seat of sensation ,the place to which impressions from the eternal world are conveyed and perceived. ALTERED SENSORIUM: it describes limitations on or problems with the brain’s ability to receive, process or interpret sensory information eg hallucinatory and confusional states, delirium, coma and sleep.

ASSESSMENT OF UNCONSCIOUS PATIENTS Most common assessment used is the physical assessment and Glasgow coma scale A.PHYSICAL ASSESSMENT: it is the systematic collection of object information that is directly observed through examination, it has 5 techniques involved I.

INSPECTION OR OBSERVATION  OVERALL APPESRANCE OF HEALTH ILLNESS  SIGNS OF DISTRESS  FACIAL EXPRESSIONS  BODY SIZE  GROOMING AND PERSONAL HYGIENE

II.

PALPATION  IT IS THE USE OF HANDS AND FIGURES TO GATHER INFORMATION THROUGH TOUCHING IN WHICH WE CAN ASSESS TEMPERTURE,TURGOR,TEXTURE,MOISTURE,VIBRATIONS,SIZE MASSESAND FLUIDS  IT HAS 3 METHODS NAMELY DORSUM,THE PALMA AND VIBRATIONS

III.

PERCUSSION: It is the examination by tapping fingers on the body to determine the condition of the internal organs by the sounds that are produced. It is done by placing a finger of the left hand firmly against a part to be examined and tapping with the finger tips of the right hand , produces sound waves by using the fingers as a hammer

IV.

ASSCULTATION: It is the listening of sound within the body with the aid of a stethoscope ,fetoscope or directly with the ear placed on the body. B. GLASGOW COMA SCALE  It is the neurological scale which leads to give a reliable and objective way of recording the state of the patient’s consciousness.  It has three ways of checking eye opening ,verbal response and motor response I.

EYE OPENING  OPEN SPONTANEOUS  TO SPEECH  TO PAIN 2  NO EYE OPENING

4 3 1

II.

VERBAL RESPONSE  ORIENTED 5  CONFUSED 4  APPROPRIATE WORD 3  INCOMPREHENSIVE SOUND 2  NO RESPONSE 1

III.

MOTOR RESPONSE  OBEY COMMAND  LOCALISE PAIN  WITHDRAWS  FLEXES  EXTENDS  NO RESPONSE

6 5 4 3 2 1

NURSING MANAGEMENT 1. Provide a bed and equipment needed, put patient in comfortable positions and cover with linen 2. Unconscious children should be observed constantly to detect any changes in vital signs and avoid injuries by falling or any wrong movements. 3. Assess vital signs includes level of consciousness ,reflexes , responses, temperature, heart/ pulse rate, respiration and blood pressure.

4. Provide adequate respiration should be maintained by keeping the patent airway. The patient should be placed in a semi prone position on one side 5. Prevent deformities ,proper body aliment with careful positioning to facilitate drainage or oral secretion ,preventing pressure on the dependent extremities. 6. Patient should be protected from injuries of any sort. 7. Maintain patient’s personal hygiene by giving bed bath, perineal care, oral care etc 8. Prevent pressure sores by regular skin care and position changing 9. The bowels should be kept in regular movement to prevent constipation 10. Concial damage can be prevented by providing regular eye care cleaning the eye with normal saline 11. Always have an organized nursing care plan

NURSING CARE PLAN NAME: Mory

STUDENT NURSE: Lumba Ng’uni

SEX:F

DATE: 12/03/20

ASSESSMENT

AGE:18

DIAGNOSI S OBJECTIVE Altered  CONFUSION mental  INCOHERENT status related to  ORIENTED TOPERSON METABOL ONLY IC  AGITATED IMBALAN As evidence to CE as disease condition. evidence to disease condition.

GOAL 

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INTERVENTION The client will be calm and help him to cope with confus ed state. Stable the client’s neurol ogical status. The client will be

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Assess patient’s level of conscious ness and changes in behavior

RATIONAL 

To provide baseline for comparis on with ongoing assessme nt findings and to detect any improvem ents or decline inpatient’ s neurologi cal function

EVALUATIO N  Pati ent is able to do dail y acti vitie s on her own and her men tal stat us has imp

able to take care of himself and do his daily activiti es

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Side rails up

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For the preventio n of fall

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Limit noise and environm ental stimulatio n

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To prevent additional confusion

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Frequentl y mention time, place and date. Give short simple explanati ons each time you perform a procedur e or task

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To decrease confusion

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Speak slowly and clearly and allow time to respond

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To reduce frustratio n

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To improve client’s state of mind and his ability to do his daily duties

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Provide psycholog ical help

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