NUR 265 – Neuro UPDATED ACTUAL Questions and CORRECT Answers
a rare inflammatory disorder that affects the axons and/or myelin sheath of the PNS
Guillain-Barre syndrome
resulting in ascending muscle weakness or paralysis (infection)
where does Guillain Barre Syndrome start starts at the toes and works its way up
, ascending muscle weakness
decreased deep tendon reflexes
respiratory compromise (can progress into respiratory failure)
loss of bowel & bladder control
ataxia
parasthesias
S/S of Guillain-Barre Syndrome pain/hypersensitivity
dysrhythmias
tachycardia
facial weakness
dysphagia
diplopia
difficulty speaking
how does the immune system react to overreacts to the infection and destroys the myelin sheath
infection from GBS?
AIRWAY!!
What is the priority with GBS?
*pt may have to be on a ventilator
what precautions might a pt with GBS have fall precautions because of the weakness
to be on?
CSF protein elevated
labs for guillain-barre syndrome
WBC elevated
MONITOR RESPIRATORY STATUS - MAINTAIN AIRWAY
HOB elevated
encourage cough & deep breath (use of IS)
Interventions for Guillain-barre syndrome monitor cardiac status (tele) - dysrhythmias
pain management
assess for complications of mobility
promote communication
- plasmapheresis (earlier the better) - decreases circulating bodies
Tx for Guillain Barre syndrome - IVIG
- may need to treat BP
Glascow Coma Scale (GCS) A neurological scaled used to determine the level of consciousness of a patient.
Highest score for Glasgow Coma Scale 15 - fully conscious
if a pt's GCS score is 8 or lower, what must intubate
you do?
Lowest score on Glasgow coma scale 3 (deep coma)
3 categories for GCS eyes, verbal, motor
What score can a rock get on GCS? 3
The worst (lower) a pt's GCS score = the more damage to the brain
How many points on a GCS does the pt 2 or more points
need to drop before you need to notify the
HCP?
New findings of abnormal flexion (upper extremities)
When doing a physical assessment, what
Pinpoint or dilated non reactive pupils
changes should you notify the HCP about?
Sudden or subtle changes in neurological status
Earliest sign of neurological deterioration Change in LOC
a rare inflammatory disorder that affects the axons and/or myelin sheath of the PNS
Guillain-Barre syndrome
resulting in ascending muscle weakness or paralysis (infection)
where does Guillain Barre Syndrome start starts at the toes and works its way up
, ascending muscle weakness
decreased deep tendon reflexes
respiratory compromise (can progress into respiratory failure)
loss of bowel & bladder control
ataxia
parasthesias
S/S of Guillain-Barre Syndrome pain/hypersensitivity
dysrhythmias
tachycardia
facial weakness
dysphagia
diplopia
difficulty speaking
how does the immune system react to overreacts to the infection and destroys the myelin sheath
infection from GBS?
AIRWAY!!
What is the priority with GBS?
*pt may have to be on a ventilator
what precautions might a pt with GBS have fall precautions because of the weakness
to be on?
CSF protein elevated
labs for guillain-barre syndrome
WBC elevated
MONITOR RESPIRATORY STATUS - MAINTAIN AIRWAY
HOB elevated
encourage cough & deep breath (use of IS)
Interventions for Guillain-barre syndrome monitor cardiac status (tele) - dysrhythmias
pain management
assess for complications of mobility
promote communication
- plasmapheresis (earlier the better) - decreases circulating bodies
Tx for Guillain Barre syndrome - IVIG
- may need to treat BP
Glascow Coma Scale (GCS) A neurological scaled used to determine the level of consciousness of a patient.
Highest score for Glasgow Coma Scale 15 - fully conscious
if a pt's GCS score is 8 or lower, what must intubate
you do?
Lowest score on Glasgow coma scale 3 (deep coma)
3 categories for GCS eyes, verbal, motor
What score can a rock get on GCS? 3
The worst (lower) a pt's GCS score = the more damage to the brain
How many points on a GCS does the pt 2 or more points
need to drop before you need to notify the
HCP?
New findings of abnormal flexion (upper extremities)
When doing a physical assessment, what
Pinpoint or dilated non reactive pupils
changes should you notify the HCP about?
Sudden or subtle changes in neurological status
Earliest sign of neurological deterioration Change in LOC
