NUR 170
EXAM 2 STUDY GUIDE
Concepts Of Medical–Surgical Nursing
Galen College of Nursing
, lOMoARcPSD|51648332
TOPICS
CHAPTER 38: ASSESSMENT OF THE NERVOUS SYSTEM
Changes in the Nervous System Related to Aging
- Slower cognitive processing time
o Provide sufficient time for the affected older adult to respond to questions and/or
direction. This allows adequate time for processing and helps differentiate normal
findings from neurologic deterioration
- Recent memory loss
o Reinforce teaching by repetition, using written teaching and memory aids such as
electronic alarms or applications for electronic devices that provide frequent
alerts. The greatest loss of brain weight is in the white matter of the frontal lobe.
Repetition helps the patient learn new information and recall it when needed.
- Decreased sensory perception of touch
o Remind the patient to look where his or her feet are placed when walking
o Instruct the patient to wear shoes that provide good support when walking.
o If the patient is unable, change his or her position frequently (every hour) while
he or she is in bed or chair
o Teach the patient to check water temperature with a thermometer due to decreased
lower extremity sensation caused by decreased circulation.
- Possible change in perception of pain
o Ask the patient to describe the nature and specific characteristics of pain
o Monitor additional assessment variables to detect possible health problems
- Change in sleep patterns
o Ascertain sleep patterns and preferences. Ask if sleep pattern interferes with
ADLs
o Adjust the patient’s daily schedule to his or her sleep pattern and preference as
much as possible (e.g., evening vs. Morning bath)
- Altered balance and/or decreased coordination
o Instruct the patient to move slowly when changing positions
o If needed, advise the patient to hold on to handrails when ambulating
o Assess the need for an ambulatory aid, such as a cane or walker.
- Increased risk for infection
o Monitor the patient carefully for signs and symptoms of infection
**BE AWARE that a change in LOC and orientation is the earliest and most reliable indication
that central neurologic function has declined! If a decline occurs, contact the Rapid Response
Team or primary health care provider immediately. Perform a focused assessment as described
later in this chapter to determine if additional changes are present.
Downloaded by Benjamin Luca ()
, lOMoARcPSD|51648332
Assessment of Cognition
- Perform assessment during the following care interactions
o On admission to and discharge from an institutional care setting
o On transfer from one care setting to another
o Every 4-8 hours throughout hospitalization or per agency protocol
o Following major changes in pharmacotherapy
o With behavior that is unusual for the person and/or inappropriate to the situation
- Assess and document (noting “sometimes”, “frequently”, or “always” as observed):
o Does the patient respond to voice; require being shaken awake to communicate;
doze off during a conversation or when no activities occur; or not respond to
voice or touch?
o Is speech clear or understandable; disoriented to person, place, or time;
inappropriate; or incomprehensible/garbled?
o Can the patient name the place, reason for admission or visit, month, and age?
o Can the patient follow one-step commands: open/close eyes; make fist/let go?
o Can the patient switch to a different topic or activity versus lose the thread of the
conversation or be easily distracted (inattention)?
o Can the patient recognize a familiar object and its purpose or a familiar person
and name relationship?
o Can the patient respond relevantly and quickly?
o Does the patient have unrealistic thoughts or act distrustful of others (e.g., does
not dare to take his/her medicine; says that people are “listening”)?
o Is the patient cooperative, euphoric, hostile, anxious, withdrawn, or guarded?
o Is the patient’s appearance, behavior, or facial expression appropriate for the
situation?
An example of a standard rapid neurologic assessment tool is the Glascow Coma Scale (GCS).
The GCS is used in many acute care settings to establish baseline data in each of these areas: eye
opening, motor response, and verbal response. The patient is assigned a numeric score for each
of these areas. The lower the score, the lower the patient’s neurologic function. For patients who
are intubated and cannot talk, record their score with a “t” after the number for verbal response.
The highest possible score is 15.
**A decrease in 2 or more points in the GCS is clinically significant and should be
communicated to the primary health care provider immediately. Other findings requiring urgent
communication with the primary health care provider include a new finding of abnormal flexion
or extension, particularly of the upper extremities (decerebrate or decorticate posturing); pinpoint
dilated nonreactive pupils; and sudden or subtle changes in mental status. Remember, a change
in mental status is the earliest sign of neurologic deterioration! Communicate this to the Rapid
Downloaded by Benjamin Luca ()
EXAM 2 STUDY GUIDE
Concepts Of Medical–Surgical Nursing
Galen College of Nursing
, lOMoARcPSD|51648332
TOPICS
CHAPTER 38: ASSESSMENT OF THE NERVOUS SYSTEM
Changes in the Nervous System Related to Aging
- Slower cognitive processing time
o Provide sufficient time for the affected older adult to respond to questions and/or
direction. This allows adequate time for processing and helps differentiate normal
findings from neurologic deterioration
- Recent memory loss
o Reinforce teaching by repetition, using written teaching and memory aids such as
electronic alarms or applications for electronic devices that provide frequent
alerts. The greatest loss of brain weight is in the white matter of the frontal lobe.
Repetition helps the patient learn new information and recall it when needed.
- Decreased sensory perception of touch
o Remind the patient to look where his or her feet are placed when walking
o Instruct the patient to wear shoes that provide good support when walking.
o If the patient is unable, change his or her position frequently (every hour) while
he or she is in bed or chair
o Teach the patient to check water temperature with a thermometer due to decreased
lower extremity sensation caused by decreased circulation.
- Possible change in perception of pain
o Ask the patient to describe the nature and specific characteristics of pain
o Monitor additional assessment variables to detect possible health problems
- Change in sleep patterns
o Ascertain sleep patterns and preferences. Ask if sleep pattern interferes with
ADLs
o Adjust the patient’s daily schedule to his or her sleep pattern and preference as
much as possible (e.g., evening vs. Morning bath)
- Altered balance and/or decreased coordination
o Instruct the patient to move slowly when changing positions
o If needed, advise the patient to hold on to handrails when ambulating
o Assess the need for an ambulatory aid, such as a cane or walker.
- Increased risk for infection
o Monitor the patient carefully for signs and symptoms of infection
**BE AWARE that a change in LOC and orientation is the earliest and most reliable indication
that central neurologic function has declined! If a decline occurs, contact the Rapid Response
Team or primary health care provider immediately. Perform a focused assessment as described
later in this chapter to determine if additional changes are present.
Downloaded by Benjamin Luca ()
, lOMoARcPSD|51648332
Assessment of Cognition
- Perform assessment during the following care interactions
o On admission to and discharge from an institutional care setting
o On transfer from one care setting to another
o Every 4-8 hours throughout hospitalization or per agency protocol
o Following major changes in pharmacotherapy
o With behavior that is unusual for the person and/or inappropriate to the situation
- Assess and document (noting “sometimes”, “frequently”, or “always” as observed):
o Does the patient respond to voice; require being shaken awake to communicate;
doze off during a conversation or when no activities occur; or not respond to
voice or touch?
o Is speech clear or understandable; disoriented to person, place, or time;
inappropriate; or incomprehensible/garbled?
o Can the patient name the place, reason for admission or visit, month, and age?
o Can the patient follow one-step commands: open/close eyes; make fist/let go?
o Can the patient switch to a different topic or activity versus lose the thread of the
conversation or be easily distracted (inattention)?
o Can the patient recognize a familiar object and its purpose or a familiar person
and name relationship?
o Can the patient respond relevantly and quickly?
o Does the patient have unrealistic thoughts or act distrustful of others (e.g., does
not dare to take his/her medicine; says that people are “listening”)?
o Is the patient cooperative, euphoric, hostile, anxious, withdrawn, or guarded?
o Is the patient’s appearance, behavior, or facial expression appropriate for the
situation?
An example of a standard rapid neurologic assessment tool is the Glascow Coma Scale (GCS).
The GCS is used in many acute care settings to establish baseline data in each of these areas: eye
opening, motor response, and verbal response. The patient is assigned a numeric score for each
of these areas. The lower the score, the lower the patient’s neurologic function. For patients who
are intubated and cannot talk, record their score with a “t” after the number for verbal response.
The highest possible score is 15.
**A decrease in 2 or more points in the GCS is clinically significant and should be
communicated to the primary health care provider immediately. Other findings requiring urgent
communication with the primary health care provider include a new finding of abnormal flexion
or extension, particularly of the upper extremities (decerebrate or decorticate posturing); pinpoint
dilated nonreactive pupils; and sudden or subtle changes in mental status. Remember, a change
in mental status is the earliest sign of neurologic deterioration! Communicate this to the Rapid
Downloaded by Benjamin Luca ()
