N213: Health Differences Across the Life Span 3

N213: Health Differences Across the Lifespan 3 Study Guide

©2017 Achieve Test Prep Page 84 of 204 2.2 Neurological Diseases Myasthenia Gravis This disease is an autoimmune disease that affects the neuromuscular system. It is also known as MG. The cause is still unknown, but the autoimmune process is thought to be triggered by a virus. The neuromuscular system is attacked by the body’s own immune system and causes severe muscular fatigue. It is progressive and can lead to dysfunction with breathing, swallowing, chewing, and Spontaneous: eyes open and blinking Opens eyes to verbal command Opens eyes to pain response (face excluded) Oriented to person, place, and time 4 Points Confused conversation, but able to answer questions 3 Points Inappropriate responses, discernible words 2 Points None 1 Point Obeys command for movement 6 Points Moves to painful stimulus 5 Points Withdraws from pain 4 Points Abnormal (spastic flexion) decorticate posture 3 Points Extensor (rigid) posture, decerebrate posture 2 Points None 1 Point Total: 3 to 15 The way the scale works is to begin the appropriate commands and give the patient a number for each. At the end of the assessment, add up the numbers to find the total GCS score. The lower the number on the GCS scale, the lower the patient’s level of consciousness. For instance, a person with a GCS of three is considered comatose. Be prepared to find these numbers very quickly in emergency situations. Emergency medical personnel will always inquire about the patient’s GCS immediately after assuming care. 4 Points 3 Points 2 Points 1 Point None Verbal Response Motor Response 2.1 Glasgow Coma Scale One important part of a neurological assessment is the Glasgow coma scale. It is imperative that nurses know what this scale is and what the numbers mean in order to communicate effectively with other medical emergency personnel as to which level of consciousness a patient is at. This applies to any emergency, but is highly used in neurological emergencies. Glasgow coma scale Eye Opening Response