訪問看護で使えるフィジカルアセスメント④～意識～
訪問看護で使えるフィジカルアセスメント④～意識～
訪問看護で使えるフィジカルアセスメント④は意識のアセスメントについてです。
意識とはなにか、また評価のポイントについてお伝えします。
意識を構成する2大要素とは
意識は2つの重要な要素から成り立っています。意識を構成する2大要素は、覚醒と認識です。
覚醒とは、目が覚めていて認識ができることです。認識とは、周囲で起きている事を正しく理解できることです。また反応できることでもあります。
脳中枢神経系などが正常に機能していれば、覚醒も認識も行えます。しかし、このどちらかが正しく行われていない時を意識が悪い（意識障害）と呼びます。
意識障害の例
例えば、大きな声をかけても目を覚まさないのは、覚醒が悪い意識障害です。目が覚めているが、辻褄の合わない言動がみられるときは、認識が悪い意識障害です。
目が覚めていなければ（覚醒していない）、必然的に認識も出来ません。目が覚めないというのは、誰がみても分かる意識障害ですが、認識が悪いのは意識障害として見落とされがちなので注意が必要です。ちなみに見当識障害は認識が悪い意識障害です。
例外として、目が覚めてないが正常な状態があります。これは睡眠で意識障害ではありません。
意識障害の評価
意識障害が出現していないのかを評価するのは、一般的には評価ツールを用います。メジャーな評価ツールはGCSやJCSがあります。
なんとなく意識が悪いではなく、ツールを使用したほうが客観的に評価できますし、共通言語になります。よって評価ツールを使うことをおすすめします。
「いつもしっかりしている患者さんが、今日は名前も生年月日も言えないです。」でも伝わりますが、JCSⅠ‐３ですの方が共通認識しやすいです。
意識障害の原因
意識障害の原因は多岐に及びます。原因のアセスメントにはAIUEOTIPSがおすすめです。
意識障害を伴い緊急性があるものとしては、脳卒中・ショックなどがあります。脳卒中は血圧が上がっていることがほとんどです。意識障害を伴うショックは血圧が著しく低下しています。
重篤な意識障害がある時は、呼吸や脈が触れるのかを確認することが必要となります。
最後までお読みいただきありがとうございます。
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How many CED players have been manufactured over what time span?
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Inventory investments are one among the preferred activities to extend the earnings of assorted buyers.
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The original site of the institute was left with out patients as they were settled elsewhere.
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However, there was another “pony” car during his tenure at Ford, and Iacocca is less freely associated with the birth of the Ford Pinto.
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It’s how long this race will final that’s up for discussion.
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J.P. Morgan, along with James Stillman of National City Bank and George Baker of First National Bank, were among several financiers who attempted to bail out some of the trust companies being hit hardest by bank runs.
The match started with five consecutive excessive-high quality attracts, earlier than Carlsen received a closely-contested eight-hour struggle in Sport 6 that, with 136 strikes, was the longest ever game in a World Chess Championship.
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And it isn’t like we do not have to cut our deficits.
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Nonetheless, destiny is about to flip his life again.
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Ernest Hemingway, who helped popularize the time period “Misplaced Era” in his novel “The Solar Additionally Rises,” was one of the leaders of this group of expatriates who fled to Paris.
The nations alongside the Caspian coastline have invested closely in capturing these energy resources, leveraging their maritime assets to bolster their economies.
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It seems that the brains behind the “Star Wars” franchise are sticking with their current follow of pre-holiday roll outs, shifting the subsequent chapter of the Skywalker saga for December 2017 after the latest success of “The Pressure Awakens.” Even the film business’s boy of summer time is getting in on the act: Michael Bay’s Benghazi action flick “13 Hours” hit the massive screen in January.
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This division was made specific with the outbreak of civil struggle in Spain in July 1936.
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The 2020 events have been cancelled in response to the COVID-19 pandemic.
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