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[간호학 건강사정] 신경계 검진에 대한 자료입니다.
목차
신경계 검진
1. 구조와 기능
중추신경계
말초신경계
척수반사
운동신경로
감각신경로
2. 신경계 검진
주관적 자료
객관적 자료
뇌신경
운동계
감각계
반사
신경계 재검사
본문내용
5)Glasgow Coma scale(GCS)
Best eye response (E)
There are 4 grades starting with the most severe:
1. No eye opening
2. Eye opening in response to pain. (Patient responds to pressure on the patient’s fingernail bed; if this does not elicit a response, supraorbital and sternal pressure or rub may be used.)
3. Eye opening to speech. (Not to be confused with an awaking of a sleeping person; such patients receive a score of 4, not 3.)
4. Eyes opening spontaneously
Best verbal response (V)
There are 5 grades starting with the most severe;
1. No verbal response
2. Incomprehensible sounds. (Moaning but no words.)
3. Inappropriate words. (Random or exclamatory articulated speech, but no conversational exchange)
4. Confused. (The patient responds to questions coherently but there is some disorientation and confusion.)
5. Oriented. (Patient responds coherently and appropriately to questions such as the patient’s name and age, where they are and why, the year, month, etc.)
Best motor response (M)
There are 6 grades starting with the most severe:
1. No motor response
2. Extension to pain (adduction of arm, internal rotation of shoulder, pronation of forearm, extension of wrist, decerebrate response)
3. Abnormal flexion to pain (adduction of arm, internal rotation of shoulder, pronation of forearm, flexion of wrist, decorticate response)
4. Flexion/Withdrawal to pain (flexion of elbow, supination of forearm, flexion of wrist when supra-orbital pressure applied ; pulls part of body away when nailbed pinched)
5. Localizes to pain. (Purposeful movements towards painful stimuli; e.g., hand crosses mid-line and gets above clavicle when supra-orbital pressure applied.)
6. Obeys commands. (The patient does simple things as asked.)
참고문헌
이강이 외, 개정 3판 건강사정 현문사(2007)
강경희 외, 건강사정. 정담미디어 (2006)
http://en.wikipedia.org/wiki