Glasgow Coma Scale

The Glasgow coma scale is used to describe a person’s level of consciousness. It is used to assess the degree of a brain injury and aids in the identification of causes of unconsciousness because it is trustworthy in documenting a person’s first and subsequent levels of awareness. Based on eye opening, vocal reaction, and motor response measurements

What assessments will be made with this scale, and how will the results be interpreted?

The assessment involves measuring eye opening, verbal response, and physical reaction. The scale is then used to rate the best response with the final GCS score being the sum of the numbers recorded. The results are then interpreted on the scale shown below

Severe: GCS 3-8

Moderate: GCS 9-12

Mild: GCS 13-15

Identify nursing interventions in priority beginning with the initial assessment in the emergency department.

Nursing interventions in the emergency department are history, red flags, clinical examination, and investigation.

2. List all 12 Cranial Nerves and how they are tested

olfactory nerve- asking the patient to smell and be able to identify a similar smell

optic nerve- testing for pupil constriction

oculomotor nerve- asking the patient to raise and lower eyelids

trochlear nerve- by use of convergence test

Trigeminal nerve- asking the patient to identify where on their faces is being touched.

Abducens nerve-administration of the six cardinal gazes

Facial nerve- asking the patient to do soothing like frowning or smiling]

Auditory Nerve- administering Weber and Rinne tests

Glossopharyngeal nerve- noting the ability of the patient to swallow

Vagus nerve- noting the patient’s ability to speak and swallow

Spinal accessory nerve- asking the patient to shrug shoulder

Hypoglossal nerve- asking the patient to stick out their tongue, move it to the left and then to the right.

What areas of concern should the nurse include in the patient’s preparation for the assessment?

Areas of concern prior to breast examination includes defining what breast examination is, tests used, the meaning of mammography and why is it done, the expected results of the examination and how to prepare for the test and also, the difference between breast self-awareness and the traditional breast-self exam.

What areas should be addressed for the prevention and/or early detection of breast cancer?Prevention of breast cancer involves limiting if not avoiding alcohol intake, observation of personal weight and reduction in calories intake and physical involvement in exercise. Early detection of cancer can be realized by checking for lumps in the breasts or from the observations of the signs and symptoms such as nipple discharge, thickening of the nipple, nipple retraction, breast pain, skin irritation and the swelling of part or the whole breast.

During the physical exam, the nurse practitioner feels a “lump” in her breast. The practitioner knows that if this is a cancerous lump, it will exhibit which characteristics?Characteristics of cancerous lumps include feeling pain in the breast, the physical location of the tumor especially within the duct of the breasts and a hard and firm feel on the lump when touched.

a. What risk factors will the nurse question the patient about because they would place her in the high-risk category?

The risk factors for cervical cancer are; many sexual partners, early sexual activity, sexually transmitted infections, weak immune system and smoking

Reference

Saunders, Christobel; Jassal, Sunil (2009). Breast cancer (1. ed.). Oxford: Oxford University Press. p. Chapter 13