N104: Essentials of Nursing Care - Health Safety

N104: Essentials of Nursing Care – Health Safety Study Guide • Assess the patient's orientation to time, place, and person by asking questions such as, "What is the time of day?" or, "What city are we in?". Remember that a patient who has been hospitalizedmay lose track of time so it is not uncommon for a hospitalized person to not know the date or day of the week. • Assess the patient's ability to follow simple commands like, "point to your nose" or "make a fist." • Assess the patient's memory by testing immediate recall, recent memory, and remote memory. o To assess immediate recall, instruct the patient to repeat a series of numbers. Start with three numbers and gradually increase the number. The average person can accurately repeat a series of five to eight numbers. o To assess recent memory, tell the patient to remember three different facts (for example, an object, his doctor's name, and a color). Later in the assessment, ask the patient to recall the three items. o To assess remote memory, ask the patient to describe a specific time in her life (a wedding day, birth of a child, birthday, etc.). The average person will be able to give a relatively detailed account of the day. • Assess the patient's ability to concentrate by asking him to count backwards from 100. Test the patient's ability to calculate by asking him to subtract 3 from 100 several times (i.e., 100, 97, 94, 91, 88 etc.). The normal adult can complete several calculations in a minute. This test should not be used for an individual with limited education or language differences. • Assess the patient's cranial nerves either as a discrete assessment or in the context of the rest of the assessment. The cranial nerves can be remembered by using the mnemonic "On Old Olympus' Towering Top, A Finn and German Vend Some Hops." The first letter of each word in the mnemonic device will be the first letter of the corresponding cranial nerve. Cranial nerves: Nerve Name Function Test I Olfactory Smell Have patient smell a familiar odor II Optic Visual activity; visual field Have patients identify fingers; check peripheral vision III Oculomotor Pupillary reaction Shine light in the eye IV Troculear Eye movement Follow finger without moving the head V Trigeminal Facial sensation; motor function Touch the face; have patients hold mouth open VI Abducens Motor function Lateral eye movements VII Facial Motor function; sensory Smile, wrinkle face, and puff cheeks; tastes Nerve Name Function Test

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