N104: Essentials of Nursing Care - Health Safety

N104: Essentials of Nursing Care – Health Safety Study Guide (screening or full exam). For a full exam, the nurse must have a percussion hammer, wisps of cotton, glasses of cold and warm water to test sensation, and tongue depressors. Information and abnormal findings provided by unlicensed personnel should be verified during this exam. Much of the neurological exam can be done in the course of the normal assessment; for example, the nurse can assess the patient's orientation while performing other parts of the assessment. Implementation • Wear gloves and any other appropriate infection control gear (mask, protective eyewear, gown, etc.). • Wash hands before starting the exam, any time the hands or gloves become soiled,and upon completion of the exam. • Provide a quiet, well-lit, and private place for the exam. • Ensure that the examination room is warm since the patient will be exposed during different parts of the assessment. • Explain each step of the exam: what will happen, why the exam is being done, andhow the patient can help during the exam. • Explain how the results of the exam will be used. • Ask about presence or history of: o Neurological disorders o Family history of neurological disorders o Signs or symptoms of neurological disorders o History of speech or orientationproblems o History of loss of consciousness, convulsions, tremors, paralysis, loss ofmemory, trauma, or problems with any senses • Assess the patient's level of consciousness using the Glasgow Coma Scale. A score of 15 points indicates a completely normal exam. A comatose patient typically scores 7 or less. Glasgow Coma Scale Score Eye opening Spontaneously 4 To speech 3 To pain 2 None 1 Verbal Response Orientated 5 Confused 4

Inappropriate 3 Incomprehensible 2 None 1 Obeys Commands 6 Localizes to pain 5 Withdraws from pain 4 Flexion to pain 3 Extension to pain 2 None 1

Motor response

15

Maximum score • Assess the patient's language and ability to speak clearly. Ask the patient to identify common objects and match written words with pictures of them.

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