Adult Health Exam 2 Study Guide

Purpose: Establish baseline neurologic status and detect changes early.
Key Concepts: Understanding different levels of alertness and assessment:
- Alert: Fully awake and interactive.
- Lethargic: Drowsy but can be easily awakened.
- Obtunded: Requires stimuli for response.
- Stupor: Responds only to painful stimuli.
- Coma: Unresponsive to stimuli or verbal commands.
Level of Consciousness (LOC) & Orientation:
- Orientation: Person, place, time, situation (importance as early indicators for decline).
Glasgow Coma Scale (GCS):
- Components: Eye (4), Verbal (5), Motor (6).
- Interpretation: Score ≤ 8 indicates severe impairment.
Pupil Assessment:
- PERRLA: Pupils equal, round, reactive to light and accommodation. Assess size and reactivity.
Motor Function:
- Strength is measured on a scale of 0-5.
- Other assessments include drift, gait, and coordination.
Sensory Function:
- Assessment of pain, temperature, vibration, and proprioception.
Cranial Nerves: Assess cranial nerves I-XII as indicated.

Types of Alertness: Alert, lethargic, obtunded, stupor, coma.
Causes of Alterations:
- Hypoxia, hypoglycemia, stroke, head injury, drugs, infections.
Manifestations: Progression from confusion to lethargy, then stupor and coma.
Nursing Priorities:
- Ensure airway, oxygenation, glucose check, and perform frequent neuro checks.

Pathophysiology: Neurovascular changes with trigeminal nerve activation.
Types of Headaches: Tension, Cluster, Migraine.
Assessment:
- Monitor for aura, triggers, location, duration, and associated symptoms like photophobia and nausea.
Interventions:
- Create a dark and quiet room, apply cold compress, and use medications such as triptans and NSAIDs.
Patient Teaching: Avoid identified triggers, administer medication at the onset of symptoms.

Delirium:
- Characterized as acute, reversible, with fluctuating levels of consciousness (often due to infection or medications).
Dementia:
- Chronic, progressive, irreversible condition (i.e., Alzheimer's).
- Exhibits cognitive decline.
Nursing Care: Reorientation, ensure safety, and treat underlying causes.

Types of Seizures:
- Focal seizures, generalized seizures (tonic-clonic).
  - Tonic: Stiffening of muscles.
  - Clonic: Rhythmic jerking of limbs.
Nursing Actions:
- Protect the patient's head, turn to the side, do NOT restrain during seizures.
Postictal State: Patient may experience confusion and fatigue post-seizure.
Medications: Phenytoin, levetiracetam.
Causes of Seizures:
- Include cerebrovascular disease, hypoxemia, fever (in children), head injury, hypertension, CNS infections, metabolic issues, drug and alcohol withdrawal, allergies.

Coma: No arousal or awareness of surroundings.
Vegetative State: Sleep-wake cycles observed but without awareness.
Care: Focus on maintaining skin integrity, airway, nutrition, and infection prevention.

Types of Stroke:
- Ischemic: Caused by disruption of blood supply due to obstruction (thrombus or embolism), leading to tissue infarction.
- Hemorrhagic: Caused by bleeding into brain tissue, ventricles, or subarachnoid space.
FAST Assessment:
- Face droop, arm weakness, speech difficulties, recognize the time of symptom onset for treatment.
Priority Action: CT scan before administering anticoagulants.
Thrombolytic Therapy (tPA): Administer within 3-4.5 hours for ischemic stroke only, with a blood pressure threshold of <185/110.
Nursing Interventions: Swallow screen, prevention of aspiration, promotion of mobility.
Risk Factors:
- Nonmodifiable: Age, gender, ethnicity.
- Modifiable: Hypertension, cardiovascular diseases, elevated cholesterol, obesity, diabetes, oral contraceptive use, smoking, substance abuse.

Pathophysiology: Autoimmune demyelination, characterized as a progressive immune-mediated demyelination disease of the CNS.
Manifestations: Fatigue, changes in vision, muscle weakness.
Care Approaches: Manage fatigue, administer corticosteroids during relapses, promote physical mobility.

Definition: Inflammation of cranial nerve VII leading to unilateral facial paralysis.
Care Measures: Ensure eye protection and corticosteroid treatment.

Definition: Ascending paralysis post-infection.
Priority Nursing Actions: Continuous monitoring of respiratory status and vital capacity.

Pathophysiology: Associated with dopamine deficiency.
Signs and Symptoms: Includes tremor, rigidity, bradykinesia, and shuffling gait.
Manifestations:
- Cardinal Symptoms: Tremor, rigidity, bradykinesia/akinesia, and postural instability.
- Autonomic Symptoms: Sweating, drooling, flushing, orthostatic hypotension, as well as gastric and urinary retention.
- Dysphagia and Psychiatric Changes: Potential development of depression, anxiety, dementia, delirium, and hallucinations.
Treatments: Focus on symptom control and medications such as Levodopa/carbidopa.
Nursing Assessments: Monitor the degree of disability, functional changes, responses to medication, quality of speech, loss of facial expression, swallowing issues, and evidence of mental slowness or confusion.

Definition: Genetic disorders causing progressive weakening and wasting of skeletal and voluntary muscles due to genetic mutations; most are hereditary.
Most Common Type: Duchenne muscular dystrophy, inherited as a sex-linked trait.
Care Requirements: Provide respiratory support and mobility assistance.