Neuro Assessment Flashcards
(76 cards)
What are you monitoring on a neuro assessment? (NII)
alert and oriented LOC x4 (person, place, time, situation and DOB)
Pupil Size 2-4 mm PERRL
speech
HGTW, flexion, and extension bilaterally upper and lower
Sensations (pain, temp, touch, pressure)
How will you assess pain type in a pt?
Say “What do you feel or is this sharp or dull?”
irregular pattern
pt closes their eyes
How will you assess temperature for a neuro assessment?
Alcohol swab (cold) and back of hand (hot)
Assessment of Nervous System
subjective data or patterns
Pain
Main thing to remember is these are SAID by the pt and need questions
Health perception and management (med, physical, history) even if you have to call the pharmacy
nutrition patterns
elimination patterns
activity-exercise
sleep-rest
cognitive perception
self-perception and concept
role-relationship
reproductive
coping-stress tolerance
values
Health Perception and Management Questions
1 -What are your usual daily activities?
2 -Do you use alcohol, tobacco, or recreational drugs?
3 -What safety practices do you perform in a car? On a motorcycle? On a bicycle?
4 -Do you have hypertension? If so, is it managed?
5 -Have you ever been hospitalized for a neurologic problem?
Medication, health, and physical history
Nutrition Questions
1 -Are you able to feed yourself?*
2 -Do you have any problems getting adequate nutrition because of chewing or swallowing difficulties, facial nerve paralysis, or poor muscle coordination?
3 -Give a 24-hour dietary recall.
Elimination Questions
1 -Do you have incontinence of your bowels or bladder?*
2 -Do you ever experience problems with urinary hesitancy, urgency, retention?*
3 -Do you postpone defecation?
4 -Do you take any medication to manage neurologic problems? If so, what?
Activity-Exercise Questions
1 -Describe any problems you experience with usual activities and exercise as a result of a neurologic problem.
2 -Do you have weakness or lack of coordination?
3 -Are you able to perform your personal hygiene needs independently?
Sleep-Rest Questions
1 -Describe your sleep pattern.
2 -When you have trouble sleeping, what do you do?
Where do you sleep
Cognitive-Perception Questions
1 -Have you noticed any changes in your memory?
Do you experience dizziness, heat or cold sensitivity, numbness, or tingling?
Do you have chronic pain?
Do you have any difficulty with verbal or written communication?
Have you noticed any changes in vision or hearing?
Self-concepts Questions
Emotions about self
Role-Relationship Questions
changes in roles from spouse, parent, or breadwinner
Reproductive Questions
dissatisfied
tension caused in relationship
counseling?
Coping-Stress Tolerance Questions
usual pattern**
adequate to meet stressors in life
needs are unmet in the support system
Value Questions
influence to care**
Assessment of Nervous System
Objective Data
Physical exam
Objective = Physical Exam
mental status (general/cerebral function of pt functioning)
cranial nerve functions
motor function
sensory function
reflexes
Nervous System Assessment follows what sequence
logical
higher level of functioning to lower levels
- constant comparison of findings
Mental Status and Speech
LOC
Appearance and behavior (LOC, motor, posture, hygiene, expressions)
Speech (normal, slurred)
Cog Function (Time, Place, Person, and situation = knowledge, insight, solving, and calculations)
Constructional ability (mood and affect)
A patient who has deficits in self-care as evidenced by poor grooming is more likely to have
other cognitive deficits.
What diseases might affect cognitive function and need to be noted?
retardation
hallucinations
delusions
dementia
What is the 1st sign of a decrease in central neurologic function?
chnage in LOC
LOC and orientation levels
Alert -
awake and responsive, follows the command
LOC and orientation levels
Lethargic -
sleepy but arousable, drowsy, delayed response, drift to sleep
