ANSWERS|REVISION|
4 Life Functions - ✔✔1. Ventilation
2. Oxygenation
3. Circulation
4. Perfusion
Normal Urine Output Amount - ✔✔40-80 mL/hr
Remember 40
Most common life function problem - ✔✔Oxygenation
if HR changes poor number, give O2
CVP - ✔✔Normal: 2-6 mmHg
Decreased: indicate hypovolemia, treat with fluid challenge
Increased: indicate hypervolemia, treat with diuretics
Obtunded - ✔✔drowsy, decreased cough or gag reflex, risk of aspiration
Coma - ✔✔does not respond to painful stimuli, risk of aspiration
Semicomatose - ✔✔responds to painful stimuli
Stuporous - ✔✔confused, responds inappropriately
Lethargic - ✔✔Somnolent, sleepy
,GCS Scale - ✔✔Eyes, Motor, Speech.
EYES (4): Spontaneous- 4, To voice- 3, To pain- 2, None- 1.
MOTOR (6): Obeys commands- 6, Localizes pain- 5, Withdraws from pain- 4, Decorticate- 3,
Decerebrate- 2, None- 1.
SPEECH (5): Oriented- 5, Confused- 4, Inappropriate- 3, Sounds (garbled, mumbling, etc)- 2,
None, 1.
*Your pt will always be 3 or more.
Emotional State and likely Diagnosis - ✔✔Anxiety, nervousness= asthma, respir distress,
hypoxemia
Depressed= quiet or denial
Anger= electrolyte imbalance
Euphoria= drug overdose
Panic= hypoxia, tension pneumo, status asthmaticus
General malaise- subjective symptom - ✔✔electrolyte imbalance
Grades of dyspnea - ✔✔Grade 1- dyspnea after unusual exertion
Grade 2- breathlessness after hills or stairs
Grade 3- dyspnea while walking at normal speed
Grade 4- dyspnea slowly walking short distance
, Grade 5- dyspnea at rest, shaving, dressing
Vasovagal syncope - ✔✔dizziness and fainting, caused by loss of peripheral venous tone,
stimulating vagus nerve
Orthostatic hypotension - ✔✔excessive drop in BP when assuming a standing position
Carotid sinus syncope - ✔✔associated with hypersensitive carotid sinus- more common in
elderly
Cough syncope - ✔✔transient LOC following severe coughing
Fever causes - ✔✔Warm environment
Dehydration
Reaction to chemical substances/drugs
Malignant neoplasm
Connective tissue disease
Temperature normal - ✔✔36.5 - 37.5 degrees C
Blood pressure range - ✔✔90/60 to 140/90
Hemiparesis seizure posture - ✔✔abnormal positioning
could induce brain injury
Decorticate seizure posture - ✔✔arms flexed, hands clenched, legs extended
PERRLA - ✔✔pupils equal, round, and reactive to light and accommodation