Pn3 EXAM 1
1. decerebrate, decorticate, and withdrawal: Decerebrate posture is an abnormal body posture
that involves the arms and legs being held straight out, the toes being pointed downward, and the head and neck
being arched backward. The muscles are tightened and held rigidly. This type of posturing usually means there has
been severe damage to the brain.
Decorticate posture is an abnormal posturing in which a person is stiff with bent arms, clenched fists, and legs held
out straight. The arms are bent in toward the body and the wrists and fingers are bent and held on the chest. This type
of posturing is a sign of severe damage in the brain.
The difference between the two...
While decorticate posturing is still an ominous sign of severe brain damage, decerebrate posturing is usually indicative
of more severe damage at the rubrospinal tract, and hence, the red nucleus is also involved, indicating a lesion lower
in the brainstem.
Withdrawal: Withdrawing from pain, or withdrawal, is where the patient typically flexes his arms toward the pain;
however, he does not make a "purposeful" attempt to remove the pain or move his arms beyond chin level.
lates body's uncon-
2. Sympathetic nervous system: Stimulates the body's fight or flight response. Regu
scious actions. Constantly active at a basic level to maintain hemostasis.
,3. Parasympathetic nervous system: Conserves energy as it slows the heart rate, increases intestinal
and gland activity, and relaxes the sphincter muscles in the G.I. tract.
oluntary actions to
4. somatic nervous system: A subdivision of the peripheral nervous system. Enables v
be undertaken due to its control of skeletal muscles
n action the other
5. Sympathetic and parasympathetic systems: When one system increases a
decreases the action.
6. Consciousness
*Level of consciousness
, *Indicators of level of consciousness change
*Glasgow coma scale: Level of consciousness
When assessing a clients level of consciousness check eye movement, pupil changes, vitals, intake and output, pulse,
oximetry, and use Glasgow scale.
Indicators of level of consciousness change
Level of consciousness is assessed by determining the clients awareness and orientation and is the most important
indicator of change in neurological status.
Glasgow coma scale
esponse are scored
An objective tool for assessing consciousness in clients. Eye opening, verbal response, and motor r
using measurable criteria.
15 is the best score. 7 or less is considered a coma state. 3 is the worse score.
The totaled scores indicate coma severity. The changes in glasgow scale indicate changes in the clients condition.
If score dropping low, contact doctor immediately.
7. Process of assessing mental status: Requires observation of clients appearance, behavior, posture,
mood, gestures, movements, and facial expressions.
Compare these behaviors to expected behaviors of clients age, health status, education level, and social position. Assess
mood by asking about feelings.
1. decerebrate, decorticate, and withdrawal: Decerebrate posture is an abnormal body posture
that involves the arms and legs being held straight out, the toes being pointed downward, and the head and neck
being arched backward. The muscles are tightened and held rigidly. This type of posturing usually means there has
been severe damage to the brain.
Decorticate posture is an abnormal posturing in which a person is stiff with bent arms, clenched fists, and legs held
out straight. The arms are bent in toward the body and the wrists and fingers are bent and held on the chest. This type
of posturing is a sign of severe damage in the brain.
The difference between the two...
While decorticate posturing is still an ominous sign of severe brain damage, decerebrate posturing is usually indicative
of more severe damage at the rubrospinal tract, and hence, the red nucleus is also involved, indicating a lesion lower
in the brainstem.
Withdrawal: Withdrawing from pain, or withdrawal, is where the patient typically flexes his arms toward the pain;
however, he does not make a "purposeful" attempt to remove the pain or move his arms beyond chin level.
lates body's uncon-
2. Sympathetic nervous system: Stimulates the body's fight or flight response. Regu
scious actions. Constantly active at a basic level to maintain hemostasis.
,3. Parasympathetic nervous system: Conserves energy as it slows the heart rate, increases intestinal
and gland activity, and relaxes the sphincter muscles in the G.I. tract.
oluntary actions to
4. somatic nervous system: A subdivision of the peripheral nervous system. Enables v
be undertaken due to its control of skeletal muscles
n action the other
5. Sympathetic and parasympathetic systems: When one system increases a
decreases the action.
6. Consciousness
*Level of consciousness
, *Indicators of level of consciousness change
*Glasgow coma scale: Level of consciousness
When assessing a clients level of consciousness check eye movement, pupil changes, vitals, intake and output, pulse,
oximetry, and use Glasgow scale.
Indicators of level of consciousness change
Level of consciousness is assessed by determining the clients awareness and orientation and is the most important
indicator of change in neurological status.
Glasgow coma scale
esponse are scored
An objective tool for assessing consciousness in clients. Eye opening, verbal response, and motor r
using measurable criteria.
15 is the best score. 7 or less is considered a coma state. 3 is the worse score.
The totaled scores indicate coma severity. The changes in glasgow scale indicate changes in the clients condition.
If score dropping low, contact doctor immediately.
7. Process of assessing mental status: Requires observation of clients appearance, behavior, posture,
mood, gestures, movements, and facial expressions.
Compare these behaviors to expected behaviors of clients age, health status, education level, and social position. Assess
mood by asking about feelings.
