Sensorium Awake Confusion Disorientation Lethargy Obtundation Stupor Coma Recognize time, place & person Loss of ability

to think clearly. Inability to recognize time, place & person Lack of spontaneous movement or speech easily aroused but disoriented Reduced ability to be aroused and limited response to environment Condition of deep sleep or unresponsiveness and aroused only by vigorous (pain) stimulation. No motor response to any stimuli, even deep pain Sensory Functions Pain Temperature Light touch Vibration Position Discriminating Sensation Sharp safety pin and dull alternately Warm and cold water test tubes Wisp of cotton Tuning fork Down movement of big toe Interpretation Reflexes (++++) (+++) (++) (+) (-) Very brisk, hyperactive Briskier than normal Average, normal Somewhat diminished, low normal No response Motor Functions 0 1 2 3 4 5 No muscular contraction detected Barely detectable flicker or trace Active movement of the body with gravity eliminated Active movement against gravity Active movement against gravity and some resistance Active movements against full resistance without fatigue Cerebellar Functions Posture & Gait Smooth and coordinated movements Equilibrium Tandem walking (walking heel-to-toe in a straight line) Finger to nose test (touch his own nose then the finger of examiner) Romberg test (positive when a patient looses balance when eyes are closed)

Cranial Name Nerve I Olfactory (nose)

Cranial Nerve Functions and Assessment Methods Type Function Assessment Method Sensory Smell Ask the client to close eyes and identify different mild aromas, such as coffee, vanilla, peanut butter, orange/lemon, chocolate. Ask client to read Snellen-type chart; check visual fields by confrontation; and conduct an ophthalmoscopic examination Assess six ocular movements and pupil reaction

II

Optic (pupils)

Sensory

Vision and visual fields

III

Oculomotor (eyelids)

Motor

IV

Trochlear (inner eye) Trigeminal (Ophthalmic, maxillary and mandibular branches) (jaws)

Motor

Mixed

Extraocular eye movement (EOM); Movement of the pupil; movement of ciliary muscles of lens EOM; specifically, moves eyeball downward and laterally Oph S Sensation of cornea, skin of face, and nasal mucosa Max S Sensation of skin of face and anterior oral cavity (tongue and teeth) Man Mo&S Muscles of mastication; sensation of skin of face

Assess six ocular movements

Oph While the client looks upward, lightly touch the lateral sclera of the eye with sterile gauze to elicit blink reflex. To test light sensation, have the client close eyes, wipe a wisp of cotton over the pt forehead and paranasal sinuses. To test deep sensation, use alternating blunt and sharp ends of a safety pin over same areas. Max Assess skin sensation for ophthalmic branch above. Man Ask pt to clench teeth Assess the directions of gaze

VI VII

Abducens (outer eye) Facial (pass through the whole face)

Motor Mixed

EOM; moves eyeball laterally Facial expression; taste (anterior 2/3 of tongue)

VIII

IX

Vestibulocochl ear (Acoustic) (ears) Glossopharyng eal (tongue)

Sensory

Mixed

Vagus (neck)

Mixed

XI

Spinal Accessory (shoulder) Hypoglossal (tongue)

Motor

XII

Motor

Ask pt to smile, raise the eyebrows, frown, puff out cheeks, close eyes tightly. Ask pt to identify various tastes placed on tip and sides of tongue: sugar (sweet), salt, lemon juice (sour), and quinine (bitter); identify areas of taste. Vestibular branchV - Romberg test Equilibrium C Assess the ability to hear spoken Cochlear branch- Hearing word and vibrations of tuning fork Swallowing ability, tongue Apply tastes on posterior tongue for movement, taste identification. Ask the client to move the (posterior tongue) tongue from side to side and up and down Sensation of pharynx and Assessed with cranial nerve IX; assess larynx; swallowing; vocal pts speech for hoarseness cord movement Head movement; Ask the client to shrug shoulders against shrugging of shoulders resistance from your hands and turn head to side against resistance from your hand (repeat for other side) Protrusion of tongue; Ask the pt to protrude tongue at midline, moves tongue up and then move it to side to side down and side to side

Characteristic Color

Normal Infant - Yellow Adult - Brown

Bowel Elimination Abnormal White or clay (acholic stool) Black or tarry (melena) Red (hematochezia) Pale with fat (steatorrhea) Translucent mucus Bloody mucus

Odor Consistency

Pungent; affected by food type Soft, formed

Noxious change Liquid Hard Infant: more than 6x or less than once every 1-2 days Adult: more than 3x a day or less than once a week

Cause of Abnormality Absence of bile Iron ingestion or upper GI bleeding Lower GI bleeding, or hemorrhoids Malabsorption of fat Spastic constipation, colitis or excessive straining Blood in feces, inflammation or infection Blood in feces or infection Diarrhea, reduced water absorption Constipation Hypermotility or hypomotility

Frequency

Amount Shape

Constituents

Infant: 4-6 times daily or 1-3 times daily Adult: daily or 2-3 times a week 150 g per day Resembles the diameter of the rectum Undigested food, dead bacteria, fat, bile pigment, cells lining intestinal mucosa, and water

Narrow, pencil-shaped

Obstruction or rapid peristalsis

Blood, pus, foreign bodies, mucus, worms, and excess fat

Internal bleeding, infection, swallowed objects, irritation, inflammation, malabsorption syndrome, enteritis, pancreatic disease, or surgical resection of intestine

Measurement pH Protein Glucose Ketones

Normal Value 4.6 8.0, average is 6.0 None or up to 8 mg/100ml None None

Blood

Up to 2 RBCs

Specific Gravity

1.010 1.025

WBCs Bacteria Casts Odor Color and Clarity

0-4 per low-power field None None Faintly aromatic Straw, amber, and transparent 30 60 ml/hr 800 1800 ml/day (depends)

Amount in 24hrs (adult)

Implications Urine that stands for several hours becomes alkaline If present (albumin): renal disease If present: Diabetes Present in dehydration, starvation or excessive aspirin usage and in poorly controlled DM Present in damaged glomeruli or tubules, trauma, disease or surgery of the lower urinary tract High: in dehydration, reduced renal blood flow, and increase in ADH Low: in overhydration, early renal disease, and inadequate ADH secretion Greater numbers indicate UTI May indicate UTI, if present Indicates renal alteration If fetid infected urine; if with sweet odor, urine has high glucose Darker if concentrated urine; almost clear or very pale yellow if diluted urine; and pink, bright red or rusty brown in hematuria Below 1,200 ml may indicate decreased blood flow to the kidneys Anuria - <100/day

Genitourinary System Patterns Some Associated Factors Polyuria production of abnormally large amounts -Ingestion of caffeine or alcohol; Diuretics of urine by the kidneys (more than 2,000 in 24hrs Hx of DM, DI, or Kidney disease Oliguria low urine output, usually less than Decreased fluid intake; Signs of dehydration, Hypotention, 500ml/day or 30ml/hr shock or heart failure Anuria lack of urine production Kidney Disease Frequency voiding of frequent intervals Pregnancy Nocturia voiding 2 or more times at night Increased fluid intake; UTI Urgency feeling that the person must void Psychologic stress; UTI Dysuria voiding that is either painful or difficult UTI; Hesitancy, hematuria, pyuria Enuresis involuntary urination in children beyond Family history, difficult access to toilet facilities, Home the age when voluntary bladder control is acquired Stresses (4-5y/o) Incontinence involuntary urination Bladder inflammation; difficulty in independednt toileting; leakage when coughing, sneezing; Cognitive impairment Retention impaired bladder emptying of urine Recent anesthesia; Recent perineal surgery; presence of accumulates and bladder becomes overdistended perineal swelling, medications, lack of privacy

Oral Agent

Oral Hypoglycemic Agents (OHA): Types and Characteristics Doses Max Max Peak/Durati Side Effects (mg) Dose effective on Contraindication (mg) dose (mg)*

1. Sulfonylurea (SU)
- directly stimulating the pancreas to secrete insulin; MIDE

SE: GI symptoms and dermatologic reactions A. Glibenclamide B. Glipizide (Minidiab) C. Glimepiride (Solosa, Norizec) 1,2,3 D. Gliclazide (Dianorm, Glubitor) 80 8 OD 320 OD 4 OD 2.5, 5 2.5, 5 10 BID 20 BID 10 OD 10 OD - BID

E. Chlorpropamide (Diabenese) 2. Non-SU insulin secretagogues A. Nateglinide (Starlix) B.Repaglinide (NovoNorm)

250

500 OD

4 h/ 24 h Intermediat e-acting 1-3 H/15 H Short-acting 24 h Intermediat e-acting 2 h/ 18 h Intermediat e-acting 4 h/60 h Long-acting

Hypoglycemia Hypoglycemia

Hypoglycemia Hypoglycemia

Hypoglycemia, Steven-Johnsons

120 0.5,1,2

120 TID

120 TID 3-4 h SE: Hypoglycemia CI: Kidney and Liver Failure SE: GI intolerance CI: Kidney failure, liver disease, lactic acidosis SE: Increase in liver enzymes, edema, weight gain

3. Biguanides: Metformin
- facilitating the action of insulin on peripheral receptor sites.

500,850, 1000

850 TID

1000 BID

7-12 h

4. Thiazolidinediones (TZD)
- enhance insulin reaction at the receptor site without increasing insulin secretion. Impair liver function, decrease effectiveness of hormonal contraceptivesand can cause ovulation in perimenopausal anovulatory women, making pregnancy possible.

4,8

8 OD, 4 BID

4 BID

24 30 h

A. Rosiglitazone (Avandia) B. Pioglitazone (Piozone, Actos, Prialta) 5. Alpha-glucosidase inhibitor

- delays the absorption of glucose in the intestinal system; safe to use because it is not systematically absorbed

15,30,45

45 OD

45 OD

SE: Increase in liver enzymes, edema, weight gain

a. Acarbose (Glucobay, Gluconase) 6. Voglibose (Basen) 7. DPP-IV inhibitors A. Sitagliptin (Januvia)

50, 100 200, 300 mcg 25, 50, 100

100 TID

50 TID

100 mcg OD

25 mg if Crea Cl <30 ml/min, 50mg if Crea Cl 3050 ml/min

1-4 h/ t1/2 12.4 h

SE: Flatulence, diarrhea CI: Kidney failure, liver disease SE: Flatulence, diarrhea Minimal risk of hypoglycemia

B. Vildagliptin (Galvus)

50 mg

50 mg BID

1-2 h/ t1/2 1.7-2.5 h

HYPOGLYCEMIA
Manifested by: Cold and clammy skin, disorientation, tachycardia, confusion, abnormal behavior or both, such as the inability to complete routine tasks. Visual disturbances, such as double vision and blurred vision. Seizures, though uncommon. Loss of consciousness, though uncommon. Heart palpitations, Shakiness, Anxiety, Sweating, Hunger, Tingling sensation around the mouth. Managed by: >High glucose drink like orange juice or among unconscious IV D 50/50 >Diabetic patient should carry packets of table sugar or a candy roll at all times for use at the onset of hypoglycemic symptoms. >Tablets containing 3 g of glucose are available (Dextrosol). The educated patient soon learns to take the amount of glucose needed and avoids the excess that may occur with eating candy or drinking orange juice, causing very high hyperglycemia. >A glucagon emergency kit (1 mg) should be provided to every diabetic receiving insulin therapy, and family or friends should be instructed how to inject it intramuscularly in the event that the patient is unconscious or refuses food. >If more severe hypoglycemia has produced unconsciousness or stupor, the treatment is 50 mL of 50% glucose solution by rapid intravenous infusion. >If intravenous therapy is not available, 1 mg of glucagon injected intramuscularly will usually restore the patient to consciousness within 15 minutes to permit ingestion of sugar. >If the patient is stuporous and glucagon is not available, small amounts of honey or syrup or glucose gel (15 g) can be inserted within the buccal pouch, but, in general, oral feeding is contraindicated in unconscious patients. >Rectal administration of syrup or honey (30 mL per 500 mL of warm water) has been effective.