HA exam 2 - neurological

Glasgow coma scale - eye opening

spontaneously - 4, to speech - 3, to pain - 2, unresponsive - 1

Glasgow coma scale - verbal response

oriented - 5, confused - 4, inappropriate words - 3, incomprehensible - 2, no response - 1

Glasgow coma scale - motor response

obeys commands - 6, moves to localized pain - 5, abnormal flexion - 3, abnormal extension - 2, no response - 1

abnormal flexion

decorticate posturing

abnormal extension

decerebrate posturing

fencing response

suggests damage to brain’s cortex following head trauma

mini mental state exam

measures orientation and cognitive function; 30 is max possible score, score of 23 or higher means cognition is within normal limits (WNL)

delirium

rapid onset, fluctuating, reversible, altered concsiousness, significant inattention and lack of concentration, impaired immediate recall memory, hyper or hypoactive, sleep-wake cycle often reversed

dementia

insidious, progressive, irreversible

causes of delirium

dementia; electrolyte disorder; lung, liver, heart, kidney, brain; infection; rx drugs; injury, pain, stress; unfamiliar environment; metabolic

cranial nerve 1

olfactory - smell

cranial nerve 2

optic - vision

cranial nerve 3

oculomotor - move eyes

cranial nerve 4

trochlear - move eyes and eyelids

cranial nerve 5

trigeminal - facial sensation and motor

cranial nerve 6

abducens - lateral eye movement

cranial nerve 7

facial - face movement and taste buds

cranial nerve 8

vestibulocochlear - hearing and balance

cranial nerve 9

glossopharyngeal - taste, swallow, gag reflex

cranial nerve 10

vagus - heart rate, rest and digest

cranial nerve 11

accessory - moves head

cranial nerve 12

hypoglossal - moves tongue