NUR 242 Advanced Exam 3 Complete study guide|Galen College of Nursing
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NUR 242
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Galen College Of Nursing
NUR 242 Advanced Exam 3 Complete study guide|Galen College of Nursing.Every person receiving care has the potential to become a neuro patient.
When change develops have a thorough, accurate, and execute crucial steps for safety.
- 1
st symptom of a neuro problem is a change in LOC, and restlessn...
nur 242 advanced exam 3 complete study guide|galen college of nursing
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NUR 242
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Advanced Exam 3
Every person receiving care has the potential to become a neuro patient.
When change develops have a thorough, accurate, and execute crucial steps for safety.
- 1st symptom of a neuro problem is a change in LOC, and restlessness.
Assessment:
- Behavior- affect, irritable, and restlessness.
- Speech- appropriate or slurring.
- Arousal- spontaneous, to voice, tactile stimuli, or forceful stimuli.
- Pupils- wide, constricted, or fixed.
- Family history, genetics, current health problems, LOC, memory and attention span,
language, cranial nerve assessment, sensory and motor function, and cerebellar.
Neuro Emergencies include ischemic or embolic injury, anticoagulation therapy, postop, trauma,
electrolyte imbalance, fever, and acute withdrawal syndrome.
Glasgow Coma Scale: Look at slide #7.
- Mild: 13-15. Normal to lethargic, mildly disoriented. (narcotics)
- Moderate: 9-12. Lethargic to change in LOC, follows commands with arousal, confused.
- Severe: 3-8. Comatose, no eye opening or verbalization. Does not follow commands.
Includes posturing. Decorticate- problems cervical spine, or cerebral hemisphere.
Decerebrate- problem with midbrain and pons.
Oh Oh Oh, To Touch and Feel Virgin Girl’s Vagina, and Hymen.
1) Olfactory- smell.
2) Optic- visual acuity, visual fields.
3) Ocularmotor- pupil reaction, eye movement, and elevation of eye lid.
4) Trochlear-
5) Trigeminal- facial sensation, and mouth opening.
6) Abducens- extraoccular motor.
7) Facial- facial movements.
8) Acoustic- hearing, and equilibrium. (add an A).
9) Glossopharyngeal- gag reflex.
10) Vagus- vocalization.
11) Accessory- shrug shoulders.
12) Hypoglossal- stick tongue out.
, Diagnostics for Neuro Disorders: blood cultures, skull and spine scans, lumbar puncture,
cerebral angiography, CT scan, MRI, evoked response to measure electrical to the brain, PET
scan, MEG, EMG, EEG, and muscle and nerve biopsies.
Spinal Cord Injury- motor and sensory function, reflexes, and control of elimination. The higher
the inury, the most loss of function they have. Remember ABC’s!
- Traumatic Incomplete/ Partial: able to convey SOME messages to the brain. They retain
some sensation and possible some motor function below the injury.
- Complete: complete loss of motor function, and sensation below the area of injury.
- Hyperflextion: head goes forward like in head on collision, dive into shallow pools or
thrown off horse or motorcycle.
- Hyperextension: head goes backwards like in rear ending, football tackle, diving, or
elderly falling to the floor.
- Compression: falling onto your butt or straight onto your head.
- Rotation: rollover or motorcycle accident.
Secondary Injury edema, ischemia, and vasodilation r/t inflammation cascade. Hemorrhage,
spinal shock, neurogenic shock (emergency), and autonomic dysreflexia (emergency).
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