The patient is Kurt Johnson, a white male 48 years old. He was admitted to having a tonic-clonic seizure. The patient had a head injury after falling off a ladder at work a year and a half ago. CAT scan showed scar tissue overgrowth in the frontal lobe.
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What is Kurt’s GCS, and what does it indicate?
After the patient was stabilized, the Glasgow Coma Scale assessment was performed. The patient was breathing on his own. The assessment result was GCS 7 = E1 V2 M4. This result indicates severe brain injury.
The next morning, Kurt begins to wake up. How would you assess his level of consciousness?
The patient’s level of consciousness is determined based on their response to stimuli. Every state under “alert” is recognized as unconscious. Kurt Johnson shows no eye response, yet he reacts to verbal and pain assessments.
How would you describe Kurt’s level of consciousness?
Based on the decline of the GSC score, the patient is unconscious with response to pain (withdrawal) and verbal stimuli (incomprehensive sounds).
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What health history question should you ask about seizure activity?
It is important to determine whether the seizure the patient had was generalized or simple partial. For that, the family and co-workers of the patient need to be inquired into considering a prodrome. This includes premonitory symptoms, which may have been observed several days or hours before the actual seizure. Such symptoms mainly include irritability, problems with concentration, anxiety, disturbances of sleep, mood swings, and lightheadedness (Ko, 2013). One more symptom is ecstatic feeling, but it is rather rare. Having an aura before the seizure identifies the seizure as simple partial, while the patients suffering from generalized seizures do not tend to experience auras.
How would you test for the motor function of the facial nerve (Cranial nerve VII)?
The motor function of the facial nerve is tested through the careful observation of the signs indicating the weakness of facial muscles responsible for blinking, nasolabial folds, and mouth movements. When the facial nerve is affected, face asymmetry can be observed. As a test, the patient is asked to wrinkle their forehead, tightly close their eyes, smile, show their teeth. The affected side will have a weaker muscle response – nasolabial folds will be flatter, blinking of the affected eye will be slightly slower than that of the unaffected eye, and while speaking, the affected side of the mouth will move less than the unaffected one (Walker, n. d.).
While continuing your assessment, you note that Kurt has positive Homans signs. How would you assess for Homans signs, and what does it indicate?
To test the patient for Homans signs, the nurse needs to ask him to extend his knee and then check if the patient experiences pain in his calf during forceful dorsiflexion of the foot. The presence of pain is a positive Homans sign and might indicate deep vein thrombosis.
What further assessments should be done to check for deep vein thrombophlebitis?
The assessment for deep vein thrombophlebitis is an examination of the patient’s extremities visually and through palpation. Localized inflammation, the warmth of the skin, pain, and cord-like veins signalize thrombophlebitis. For precise results, an ultrasound of the patient’s leg and a blood test needs to be done.
Ko, D. Y. (2013). Generalized Tonic-Clonic Seizures Clinical Presentation. Web.
Walker, H. K. (n. d.). Cranial Nerve VII: The Facial Nerve and Taste. Web.