WVU Nursing 460 Combined Exam 1 Content Verified
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Mental Status Spectrum
Mental Status Exam -a wide spectrum in order to assess the patient's mental status -useful for if a patient is comatose, somnolent, obtunded, lethargic, confused, or alert & oriented -changes in mental status do...
If a patient has gone from decorticates to decerebrates, what does this mean about their condition?
this means that a patient's condition is worsening
What is the difference between decorticate and decerebrate?
-decoriate: abnormal flexion
-decerebrate: abnormal extension
*the way I remember is "decerebrate" kind of sounds like "celebrate", and when you celebrate
you extend your hands in the air
What is mild, moderate, and severe on the GCS?
-Mild: 14 to 15
^ex. patient may be confused but is still awake and alert
-Moderate: 9 to 13
-Severe: 8 or less
,^we typically call these patients comatose
When can the GCS be difficult?
when we apply noxious stimuli
^students have trouble with this because it feels like they are going against their nature, but IT IS OK
Why do we apply noxious stimuli?
some patients are unable to respond to voice, so we have to check to see if they can open their eyes
What are ethical and non-ethical forms of noxious stimuli?
Ethical
-sternal rub, trapezius pinch (hard to do in obese patients), nail bed pressure
^trapezius pinch and sternal rub are the best tests for pain localization b/c they really can't withdraw
when noxious stimuli is provided
^nail bed pressure is the best test for withdrawing
Non-Ethical
-nipple twisting and testicle squeezing
What cranial nerves are in charge of basic senses?
-CN I (smell)
-CN II (sight)
-CN VIII (hearing)
What cranial nerves are responsible for gaze control?
-CN III, IV, & VI
^we would be assessing the cardinal fields of gaze with these ones
What cranial nerves correspond with the face and oral cavity?
CN V, VII, & IX
What cranial nerve is involved with the tongue?
CN XII
What cranial nerve is involved with our gag reflex?
CN X
What cranial nerve is responsible for motor nerves of the neck?
CN XI
, Assessing Pupils
-associated with CN III
-when assessing a patient, reactivity becomes more important than pupil size
-if a patient has pupils that aren't reacting, this could be due to increased ICP
-blown pupils: when the pupil is greater than 4 mm, this indicates brainstem compression
^could indicate impending herniation
^when one pupil is larger than the other, it could indicate the ICP is greater than 20 mmHg
Cushing's Triad
-this is the classic response to increased ICP (LATE SIGN)
Triangle Effect
-wide pulse pressure (increased systolic BP)
-bradycardia
-irregular respirations
Assessing Pulse Pressure
-pulse pressure can be indicative of a change in the patient's condition
-we calculate pulse pressure by finding the difference between the systolic and diastolic blood pressure
For example...
-if a patient has a BP of 120/70, the pulse pressure would be 50
-let's say the patient's condition changes...
-the patient has a BP now of 150/70, making the pulse pressure 80
^this is indicative that the patient's condition has worsened and something is going on
What is the most important EARLY sign of increased ICP?
-change in LOC
^this is why our MSE is so important because subtle changes can be indicative of an issue
Assessing Hypo/Hyperthermia
Hypothermia
-we tend to vasoconstrict when our bodies get cold
-this decreases the amount of blood that reaches the brain (this is bad because our brain NEEDS O2)
-secondary to lowered body temperature is shivering
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