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Level of Consciousness: Descriptive guide for Glasgow Coma Scale
Conscious
Confused
Delirious
Somnolent
Obtunded
Stuporous
Comatose
3 mins
Lumbar Puncture
Indications
CSF Sample
CSF Pressure
Considerations
Empty Bladder
Side-lying Position
Between 3rd and 4th Lumbar Vertebrae
Number Tubes
Supine Position After Procedure
Contraindications
Increased ICP (Intracranial Pressure)
Infection at Puncture Site
2 mins
Maslow's Hierarchy of Needs
Physiological Needs
Oxygen, Water, Nutrition
Body temperature, Elimination, Shelter, Sexual Expression
Safety and Security
Physical Safety
Physiological Safety
Love and Belonging
Affection and Companionship
Esteem
Self Respect and Respect for Others
Self Actualization
Fulfillment
2 mins
Neurovascular Assessment 6 P's
Pain
Paresthesia
Pulse
Pallor
Pressure
Paralysis
1 min
Normal Electrolyte Lab Values
Potassium (K+)
3.5 to 5.0 mEq/L
Calcium (Ca2+)
8.5 to 10.5 mg/dL
Phosphate (PO43–)
2.5 to 4.5 mg/dL
Magnesium (Mg2+)
1.5 to 2.5 mEq/L
Sodium (Na+)
135 to 145 mEq/L
Chloride (Cl–)
95 to 105 mEq/L
2 mins
Seizure Precautions
Reduce Environmental Stimuli
Identify Triggers
Aura
Pad Side Rails
Bed Lowest Position
Oxygen and Suction Available
Consideration
Monitor Therapeutic Drug Levels
2 mins
Seizure Interventions
Maintain Airway
Side-lying Position
Support Head
Move to Floor
Benzodiazepines
Considerations
Never Restrain
No Objects in Mouth
Document Details
2 mins
5 Rights of Delegation
Right Task
Right Circumstance
Right Person
Right Direction/Communication
Right Supervision/Evaluation
1 min
Principles of Delegation
Delegation
Assigning Responsibility
Unlicensed Assistive Personnel (UAP)
Noninvasive Procedures
Licensed Practical Nurse (LPN)
Stable Patients with Predictable Outcome
Dressing Changes
Catheterization
Select Med Administration
Registered Nursing (RN)
Unstable Patients
Parenteral Therapy
Discharge Planning & Health Education
3 mins
Stages of Hypothermia
Mild
32 to 35°C (90 to 95°F)
Shivering
Moderate
28 to 32°C (82 to 90°F)
Obvious Motor Impairment
Slowed Thinking
Severe
< 28°C (< 82°F)
Shivering Stops
Paradoxical Undressing
Arrhythmias
3 mins
Hypothermia Interventions
Remove From Environment
Remove Wet Clothing
Passive Rewarming
Warm Clothing
Active Rewarming
Heated Blankets
Warm IV Solutions
Heated Oxygen
Warm Gastric Lavage
Considerations
Warm Trunk BEFORE Extremities
2 mins
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