CH 47- Neurologic System Flashcards
(36 cards)
What does a basic neurological assessment include?
LOC Vital signs (BP, P, RR) Pupil response to light Extremity strength/movement Sensation (touch, pain)
What is dysphagia?
difficultly swallowing/ eating
Neurologic assessment times
q 15 mins
q 8 hrs
q 24 hrs
What should a health history include?
Symptoms Medications Past surgeries Family History Lifestyle WHATS UP?
The Glasgow Coma Scale assesses…
Eye opening
Verbal response
Motor response (abnormal posture)
Glasgow Coma Scores:
range from 3-15
under 7=comatose pt
A physical examination includes:
LOC Mental examination Pupil response Muscle function Cranial Nerve Function
2 types of abnormal postures, assessed for in Glasgow coma scale include:
Decorticate
Decerebrate
Decorticate, abnormal posture, can be described as:
Feet plantar flexed -Legs internally rotated -Elbows flexed Wrists and fingers flexed Arms ADDucted
Decerebrate, abnormal posture, can be described as:
Feet plantar flexed -Forearms pronated -Elbows extended Wrists and fingers flexed Arms ADDucted
Decorticate can indicate
impairment of cerebral functioning
(FLEXED)
*cerebral cortex
Decerebrate can indicate
brainstem damage
(EXTENSION)
*cerebrum
PERRLA stands for
Puplis equal, round, reactive to light, reactive to accommodation
What is anisocoria?
pupils unequal in size
Causes: congenital
cataract surgery
*** if even become uneven, medical emergency
What is nystagmus?
involuntary movement of the eyes
Causes: Dilantin toxicity
brainstem injury
Laboratory tests that may be ordered to R/O underlying cause
Thyroid Vit B12 CBC Electrolytes CK -Creatine kinase VDRL- (test for Syphilis) Liver/Renal function ESR/WBC= Infection (MENINGITIS) Prolactin/cortisol= dysfunction of pituitary gland ( Brain tumor) Anticholinerterase testing/ antibody titer=MG
Why would a Lumbar puncture be performed?
to obtain Cerebrospinal fluid
-Assessing for: increased glucose, protein, bacteria, WBC, immunoglobin, antibodies, culture and sensitivity
Where is the Lumbar puncture needle usually placed on an adult?
L3-4, L4-5
Before a LUMBAR puncture, a nurse will
obtain informed consent assist in positioning -side lying -knees flexed to chest -may lean over bedside table
After a lumbar puncture, a nurse will aid in
maintaining flat bedrest 6-8 hrs
increase oral intake of fluids
Assess site for: swelling, drainage, movement of lower extremities, q 4 hrs, headache
Before a CT scan, a nurse will
administer contrast dye if ordered
-check BUN, creatinine
-allergies to iodine, shellfish
Teach: may feel a sensation of warmth
For an Allergic reaction to contrast dye, what symptoms should be assessed for?
Nausea
Diaphoresis
itching
difficulty breathing
After a CT scan, a nurse will
encourage fluids if dye used
With an MRI, a nurse must
make sure there are no pacemakers or metal on pt
administer sed
teach relaxation
