NURS 111G NEUROLOGICAL ASSESSMENT AND CARE WITH COMPLETE SOLUTIONS!!

NURS 111G NEUROLOGICAL ASSESSMENT AND CARE
WITH COMPLETE SOLUTIONS!!


neurlogical history

head injury, SCI, stroke, seizure, headache, tremors, dizziness, vertigo, numbness or
tingling, visual changes, weakness, dementia



orientation status

person, place, time, situation



how often is orientation status assessed?

every shift



alert

able to answer questions; responsive; interactive



lethargic

sluggish; falls asleep without stimulus




obtunded

arouses to intense stimulus (shake or shout)




stuporous

,no purposeful response (may grunt or move)




coma

no response




Glasgow Coma Scale

eye opening, verbal response, motor response




best eye opening 1-4

spontaneously, To speech, pain, none




best motor response 1-6

obeys verbal command, localizes pain, flexion withdrawal, abnormal flexion
(decorticate), abnormal extension (decerebrate), no response




best verbal response 1-5

oriented x3, confused, inappropriate, incomprehensible, no verbal response




deceberate posturing

rigid extension of arms and legs, downward pointing of the toes

brainstem lesion

, decorticate posturing

rigid flexion of arms, clenched fists, extended legs

cortical lesion




severe injury GCS

8 or less




moderate injury GCS

9-12




mild injury GCS

13-14




normal GCS

15




acute decreased LOC

obtain vitals and o2 sat