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Cipro tendon rupture frequency definition

Cranial Nerves Identification & Assessment
XII:Hypoglossal--tongue thrust, watch for right/left deviation(abnormal sign). Inspect tongue for atrophy.
XI:Accessory--(sternomastoid & trapezius muscles) shrug, ask client to move head against the resistance of your hand
X:Vagus--use tongue blade to inspect uvula, ask to phonate "ahhh"
IX:Glossopharyngeal--test for the presence of gag reflex, slightly tickle the back of the throat
VIII:Accustic Vestibulocochlear--Weber test, use the tunning fork
VII:Facial--smile, frown, watch for an uneven smile(abnormal sign) raise eyebrows, puff cheecks
VI:Abducens--lateral movement of the eyes
V:Trigeminal--muscles of mastication, open jaw, clench teeth. Watch for anhidrosis (no sweat or moisture on the face)
IV:Trochlear--extraoccular movement of the eyes
III:Occulomor--Pupilary size while you shine a light into the eye, watch for ptosis(droopie eyelids) miotic pupils(uneven pupil size)--signs of neurological abnormalities
note: cranial nerves III, IV, VII--eye movement, up/down, to the left and right
II: Vision--Snellen Chart, test for visual acuity & funduscopic
I:Smell--ask the patient to close eyes and ask to identify common household odors
Deep Tendon reflexes--limbs should be relaxed and in symmetric position when you use a reflex hammer on one foot compare your results with the other foot or if you are doing the elbow do the same:compare results.
This is the scale:
0=absent reflex
1+=trace, or seen only with reinforcement
2+=normal
3+=brisk
4+=nonsustained clonus(repetitive vibratory movements)
5+=sustained clonus
Reflexes rated as 0, 4+ and 5+ are considered abnormal
4+ and 5+ are considered hyperreflexia, by the way, hyperreflexia is one of the signs of hypocalcemia leading to tetany.
Reflex--------------Spinal Nerve Root involved
bicepts C5, C6 C=cervical
brachioradialis C6
triceps C7
patellar L4 L=lumbar
Achilles Tendon S1 S=sacral
Glasgow Scale= A method of assessing neurological condition on a scale 1-15. A score < 8 indicates coma. Eye opening is the most important indicator. The highest score is 15 which is normal.
Levels of Consciousness:
LOC
-----------------------Description
Full Awake, alert & oriented, understands & responds
Consciousness accordingly.
Confusion Disoriented first to time, then place, then person.
Memory deficits, restless, difficulties cipro tendon rupture frequency definition following
commands.
Lethargy Oriented to time, person and place, but
demonstrates slow mental process, sluggish
speech. Sleeps frequently, but weakens to
spoken word or gentle shake. Maintains
wakefulness with sufficient stimulation.
Obtundation Extreme rupture drowsiness, responds with one or two
word when spoken to, follows very simple
commands, requires more vigorous stimulation
to waken, and stays awake only for a few minutes
at a time.
Stupor Minimal movement, responds unintelligibly, and
wakens briefly only to repeated vigorous
stimulation.
Coma Does not respond to verbal stimuli, does not
speak. May have appropriate motor response
(withdraws from noxious stimuli), nonpurposeful
response.
Recognizing a Stroke:
S--
ask your patient to smile Which cranial nerve would you be testing?
T-- ask you patient to Talk and speak a simple sentence coherently
i.e. Today is a beautiful day.
R--ask your patient to raise both hands
Ask your patient to stick his/her tongue out. Which cranial nerve are you testing and what are the abnormal sign you are watching for?
feliz3

Source: http://allnurses.com/nclex-discussion-forum/anyone-up-for-308584-page176.html


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