Cranial Nerves
What is CN VII
Facial
What seizure happens most often in kids
Complex partial seizure
Whats the most common cause of falls
When should restraints be used
LAST RESORT
Name the 12 CN in order
Olfactory, Optic, oculomotor, trochlear, trigeminal, abduncens, facial, vestibulocochkear, glossopharyngeal, vagus, accessory, hypoglossal
What is CN is accessory
11
What are three seizure precautions
Pad rails
turn on side
suction/ oxygen at the bed
lower to ground if standing
Nothing PO
What is used to calculate a patients fall risk
Morse fall scale
Where and how should you secure the restraint
Bed frame (not moveable) quick release knot
Is CN V sensory, motor or both
Both
How do you test the trigeminal CN
Tactile discrimination
What type of seizure is a "drop attack"
Atonic
What is the greatest risk factors for falls
Hx of falls
Name three restraint substitutions
Pain/comfort measures
Scheduled position changes and tolieting
Bed/chair alarms
Place closer to the nurses station
Encourage family/friends to stay with patient
Reorient/validation therapy
Distractions
How often do you need to get an order for restraints
EVERY 24 hours
What is the name of the test for CN 2 and what does it test
Snellen chart, visual acuity
What is the main indicator of a complex partial seizure in kids
Lip smacking
T or F restraints decrease risk of falls
FALSE
What should you assess on a patient who has restraints
skin integrity
The nurse notices the patient keeps putting all 4 side rails up what should the nurse do
Document the patient put up their side rails and educate the patient that putting up all four side rails is a restraint
Name CN IV, how to test it, and if it is s, m, or both
Trochlear, Downward & inward gaze, motor
What is the difference between a tonic and Clonic seizure
Tonic=limbs stiffen
Clonic=Loss of muscle tone then jerking
Name 3 categories used to calculate fall scale
hx of falls
secondary diagnosis
ambulatory aid
IV/Heparin lock
Gait/transferring
Mental status
What are three different types of restraints
Physical, environmental, chemical
A patient sticks their tongue out and it goes to the side what CN is affected
CN XII