Chapter 65 Neurological Assessment Flashcards Preview

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Flashcards in Chapter 65 Neurological Assessment Deck (26):
0

What is assessed during a mini neuro assessments?

▪️LOC
▪ Pupil size and response
▪️Verbal responsiveness
▪️Extremity strength and movement
▪️VS

1

What is involved in a detailed neuro assessment?

▪️Mental status (cerebral function)
▪️Cranial nerve function
▪️Sensory function
▪️Motor function
▪️Reflexes

2

What is included in a mental status assessment?

▪️LOC- change is a sensitive indicator of change in neuro status
▪️Appearance and behavior
▪️Speech
▪️Cognitive function
▪️Constructional ability- simple tasks and use of common objects

3

What are some common symptoms of neurological disorders?

Pain, seizures, dizziness and vertigo, visual disturbances, muscle weakness, and abnormal sensation

4

What assessments are included in a neuro assessment?

Assessing consciousness and cognition, mental status, intellectual function, thought content, emotional status, language ability, impact on lifestyle, level of consciousness, cranial nerve assessment

5

What details related to neurological disorders are included in the health history?

Onset, character, severity, location, duration, and frequency of symptoms and signs; associated complaints; precipitating, aggravating, and relieving factors; progression, remission, and exacerbation; and the presence or absence of similar symptoms among family members.

6

What is included in a sensory assessment?

Tactile sensation, superficial pain, temperature, vibration, and position sense (proprioception), examining reflexes

7

What are some age related structural and physiological changes to the nervous system?

A decrease in the number of synapses and neurotransmitters. Slowed nerve conduction and response time. Reduced cerebral perfusion and metabolism, leading to slower mental functions. Less efficient temperature regulation. Decrease in conduction velocity in peripheral nerves due to loss of myelin. Loss of visual acuity and hearing, taste bud atrophy, decreased sense of smell, decrease in deep tendon reflexes, altered sleep patterns such as reduced stage IV sleep, reduced or absent pupillary response, reduced nerve input into muscle leading to atrophy, dulled tactile sensations

8

What is included in a motor system assessment?

Motor ability, Muscle strength, balance and coordination

9

What can a CT scan be used to detect?

*Brain contusion
*Brain calcification
*Cerebral atrophy
*Hydrocephalus
*Inflammation
*Space occupying lesions (tumors, hematomas, abscesses)
*Vascular anomalies

10

What are the nursing considerations associated with CT?

Confirm pt isn't allergic to iodine or shellfish.
Explain IV catheter will inject dye if contrast medium is used.
Explain that contrast medium may cause pt to feel flushed or have metallic taste in mouth.
*Explain to pt to lie still during test.
*Encourage pt to increase fluid after test to flush out dye.

11

What diagnostic tests are done with altered neuro function?

CT, MRI, PET Scan, SPECT, Cerebral Angiography, Myelography, Noninvasive Carotid Flow Studies, Transcranial Doppler, EEG, Electromyography (EMG), Nerve Conduction Studies, Evoked Potential Studies, Spinal Tap

12

What are some nursing consideration with MRI?

*Explain that procedure takes 1 1/2 hrs and has to stay still for 15-20 minute intervals
*Have pt remove all metallic items
*Ask pt if they experience claustrophobia and obtain Anxyolitics as needed
*Explain that the procedure is painless but can be loud and frightening and that pt can use earplugs
*Provide sedation, as ordered, to promote relaxation during test

13

What is PET Scan used for?

It's used to reveal cerebral dysfunction associated with tumors, seizures, TIAs, head trauma, some mental illnesses, DAT, Parkinson's Disease, and MS.

14

What are nursing considerations with PET Scan?

*Assure pt that test will not expose them to harmful levels of radiation
*Explain that test may require IV catheter insertion

15

How is MRI superior to CT?

It provides superior contrast of soft tissues, sharply differentiating healthy, benign and cancerous tissues and clearly revealing blood vessels.

16

What can a skull X-Ray help detect?

▪️Fractures
▪️Bony tumors or calcifications
▪️Pineal displacement (space occupying lesion)
▪️Skull or sella turcica erosion (space occupying lesion)
▪️Vascular abnormalities

17

What can spinal X-Rays detect?

▪️Spinal fx
▪️Dislocation or subluxation
▪️Destructive lesions
▪️Arthritic changes or spondylolisthesis
▪️Structural changes such as kyphosis, scoliosis and lordosis
▪️Congenital abnormalities

18

What is cerebral angiography used to detect?

▪️Stenosis or occlusion
▪️Aneurysms or AVMs
▪️Vessel displacement

19

What are nursing considerations with angiography?

▪️Confirm absence of allergies to shellfish and iodine
▪️Inform patient they must lie still during procedure
▪️Explain that patient will flushed sensation of dye injection
▪️Maintain bed rest, monitor VS and LOC
▪️Monitor catheter injection site for infection, and maintain pressure as ordered
▪️Monitor peripheral pulses in extremity used for injection
▪️Encourage fluids, unless contraindicated
▪️Monitor neuro function
▪️Monitor for adverse reactions to dye

20

What are nursing considerations with digital subtraction angiography?

▪️Confirm patient is not allergic to iodine or shellfish
▪️Anticoagulant and antiplatelet therapy must be stopped for a period before the test
▪️Explain patient must lie still
▪️Explain patient may feel flushed or metallic taste in mouth when dye is injected
▪️Tell patient to inform dr of sob immediately
▪️Encourage fluids to flush dye

21

What can EEG detect?

▪️Seizure disorders
▪️Head injuries
▪️Intercranial lesions
▪️TIA
▪️Stroke
▪️Brain death

22

What is Electromyography used to detect?

▪️Amyotrophic lateral sclerosis from muscular dystrophy
▪️Neuromuscular disorders such as Myesthenia Gravis

23

What are nursing considerations with Electromyography?

▪️Tell patient it may take one hour
▪️Warn there may be some discomfort with needle insertion
▪️Explain to stay still unless told otherwise
▪️Explain why not to take stimulants, sedatives or depressants 24 hrs before the test

24

What are some examples of neuro surgeries?

▪️Cerebral aneurysm repair
▪️Craniotomy
▪️Intercranial hematoma aspiration

25

What are some nursing diagnoses?

▪️ impaired physical mobility
▪️ impaired skin integrity
▪️ impaired urinary elimination
▪️ impaired gas exchange