solved

5. Pain is the first priority for Mrs Wong in this situation. Complete the following for the Mrs Wong in relation to this priority.
Goal(s) – (That is – What do you want to achieve for Mrs Wong in relation to her pain?)
Plan of care – list interventions (4 as a minimum) and explain the rationale for care that you would implement for Mrs Wong.
Intervention –
Rationale for care –
Intervention –
Rationale for care –
Intervention –
Rationale for care –
Intervention –
Rationale for care –
Evaluation of care (That is – What outcomes do you want to see in Mrs Wong if your interventions have been successful?)
Pertinent questions that you need to be able to answer in relation to a neurological assessment include the following:
5. How would you assess Mrs Wong’s orientation?

6. Identify and explain one test you could complete on Mrs Wong to assess her
a. Immediate memory
b. Recent memory
c. Remote memory
7. Discuss one test to assess Mrs Wong’s attention span and her ability to calculate.
8. Mrs Wongs care plan identifies ongoing GCS assessment. What are the three areas of the GCS and how does the nurse assess these.
9. Mrs Wong has a GCS of 13.
a. What does this mean?
10. Explain the 4 steps that a nurse completes when completing the GSC?
a. Check
b. Observe
c. Stimulate
d. Rate
11. Go to the RPH Standards for practice – Neurological Observations Nursing Practice Standards – Table of Contents – Painful Stimuli. What is the rationale provided for applying pressure to the side of the finger versus the nail bed?
12. How would you check Mrs Wong’s pupil response?
13. Mrs Wong’s pupils are recorded as PERRLA in the patient notes. What does this mean?
14. Name two tests to assess Mrs Wong’s
a. Reflex’s
b. Sensory function
c. Motor function

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