It doesn't work like it used to
The nurse is caring for a patient with Amyotrophic Lateral Sclerosis (Lou Gehrig's disease), the nurse understands this disease is terminal with this loss of function being the greatest cause of death.
If the nurse documents the patient is alert and oriented x's 4, what does this mean?
What is alert and oriented to person, place, time, and situation?
In B.E.F.A.S.T., the "S" represents this finding.
What is speech (slurred, receptive aphasia).
Vomiting not preceded by this can be seen with increased ICP.
What is nausea?
Then nurse should be concerned about what when caring for a patient with Trigeminal neuralgia, which affects cranial nerve V?
What is trigger points.
This disease is inherited and is marked by dance-like movements.
What is Huntington disease?
The nurse frequently assesses orientation of the patient to monitor for this, as it is an early warning for increased ICP.
What is level of consciousness/deviations from baseline/mental status changes/neuro changes
A patient who has had a stroke may experience the perceptual problem of hemianopia, which is?
What is a visual field deficit in half of the visual field?
To monitor intracranial pressure, this may be placed for monitoring.
What is a ventricular catheter (external ventricular catheter EVD)
As Guillain-Barre syndrome progresses, the nurse should understand that this cranial nerve affecting breathing will be affected.
What is Vagus CN X
A patient with Alzheimer Disease is experiencing obvious memory changes and the need for assistance with ADLs. The nurse understands this is the longest stage in the progression of Alzheimer, which is...
What is middle stage/moderate?
The nurse understands that asking their patient this will result in a clearer subjective assessment than asking specific yes or no questions.
What are open-ended questions/descriptive questions- "can you describe the sensations you are having?"
What is hemorrhagic stroke?
What are typically seen in Cushing's response (Cushing's Triad)? Bradycardia, widening pulse pressure, and irregular respirations make up this late ICP pattern.
What are Bradycardia, widening pulse pressure, and irregular respirations?
This cranial nerve controls pupillary constriction?
What is CN III, the Oculomotor nerve?
The nurse suspects this when performing the Kernig's sign and the Brudzinski's sign with positive reactions.
What is Meningitis.
A patient fell out of bed. There is no noticeable head trauma. The nurse understands that the patient still needs to be evaluated for a head injury and will monitor the patient for which duration post incident?
What is over several days, especially well for the first 24 hours.
Knowing the time of the patient's last known well is a key detail for administering this for an ischemic stroke.
What is Alteplase (tPA)?
It is important to make sure a patient has this in place when receiving mannitol.
What is in a foley catheter.
The patient experiencing disequilibrium. The nurses suspects this cranial nerve may be affected.
What is Vestibulocochlear CN VIII (Acoustic)
The nurse understands the differentiation between Bell Palsy and Trigeminal Neuralgia because the presentation shows
Bell Palsy has decreased movement of the face. Trigeminal Neuralgia presents with intense pain of the face.
The nurse is assessing a patient post traumatic brain injury (TBI). What instruction should be given to the patient with rhinorrhea?
What are do not cough, sneeze, or blow the nose.
A patient present may need to be reminded to pick up their right arm by using their left arm due to lack of proprioception. The nurse is trying to prevent this due to inattention to the right side of the body.
What is unilateral neglect?
What are decorticate and deceberate.
Name every Cranial Nerve by number.
Table 54.1 on page 1906