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Nursing 272: Final Semester > Unit 1: Neurological Assessment > Flashcards

Unit 1: Neurological Assessment Flashcards

Week 1

1
Q

Nursing Assessment: History

A
  • Chief Complaint
  • Regular Healthcare
  • Medical HX, Family HX
  • Allergies
  • Medications
  • Social HX
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2
Q

History: Regular Healthcare Includes

A
  • Name of primary care provider
  • Hx of routine health screenings (lipid screen, colonoscopy, and mammography)
  • Status of vaccines (tetanus, hepatitis, influenza, pneumonia)
  • Alterative healthcare (acupuncture, herbal medicines)
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3
Q

History: Medical Hx includes

A
  • Chronic illnesses (diabetes, hypertension, or renal disease)
  • Treatment for chronic diseases or current problem
  • Past trauma/ injury
  • Recent treatments or diagnostic studies
  • Past surgical procedure/treatments
  • Hx of father, mother, and siblings; if deceased, include cause of death
  • Hx of chronic illness (diabetes, obesity, or hypertension)
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4
Q

History: Allergies

A
  • list all medication, food, or environmental allergies
  • allergic response
  • allergy treatment
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5
Q

History: Medications

A
  • Taken on a regular basis; name, dose, frequency, and time of administration
  • Length of time on medication
  • Last time the medication was taken
  • Knowledge and presence of side effects
  • Routine monitoring of the medication by a healthcare provider
  • Self-administration of OTC products, vitamins, minerals, and alternative medications
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6
Q

History: Social Hx

A
  • age and gender
  • marital status
  • religion
  • social support networks
  • work hx; any environmental risk factors or exposures
  • smoking, alcohol use/abuse, or drug (legal and illegal) abuse
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7
Q

History: Current history of chief complaint

A
  • description of current symptoms that brought the patient to the hospital/clinic
  • review of time of onset ad presentation of symptoms
  • current treatment of symptoms
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8
Q

Nursing Assessment: Physical

A
  • Levels of Consciousness (Glasgow Coma Scale (GCS))
  • Cognitive Function
  • Cranial Nerves
  • Motor Assessment
  • Sensory System
  • Cerebellar Assessment
  • Reflex Assessment
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9
Q

Physical: Level of Consciousness

A

best indicator of neurological deterioration is a change in LOC

  • identifying patient responsiveness and orientation to person, place, and time
  • LOC assessed using Glasgow Coma Scale (GCS)
  • categories: conscious, confused, lethargic, obtundation, stupor, coma
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10
Q

Conscious

A

awake w/ appropriate speech and behavior

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11
Q

Confusion

A
  • disorientation
  • bewilderment
  • difficulty following demands
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12
Q

Lethargic

A
  • sleepiness

- slow and delayed response to stimuli

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13
Q

Obtundation

A
  • somnolence w/ drowsiness between sleep states
  • lessened interest in environment
  • slowed responses to stimulation
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14
Q

Stupor

A
  • minimal movement w/o stimulus

- requires strong vigorous stimulus and then drifts back to unresponsiveness

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15
Q

Coma

A
  • not arousable

- unresponsive

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16
Q

Physical: Cognitive Function

A
  • Mini-Mental Status Examination (MMSE) is a tool used to assess cognitive function
  • MMSE assesses patients orientation, attention, calculations, memory, and language abilities
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17
Q

Mini-Mental Status Examination (MMSE)

A

tool used to assess cognitive function
-assesses orientation, attention, calculation, memory, and language abilities
-asked to answer questions:
>Correct answer: 1 point; 30 points available
>Score below 20: cognitive impairment
-Orientation: who are you?, what is today?, where are you?
-Attention + Calculation: Count backward by seven, spell a word backwards
-Memory: Immediate: repeat these 3 words…, Recent: what did you have for breakfast?, Remote: where did you attend highschool?
-Language: what is this object in my hand?, repeat this phrase…., perform this 3 step command…

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18
Q

Physical: Cranial Nerve Assessment

A

can identify neurological impairment d/t disease or trauma in the brain

  • CN I (Olfactory)
  • CN II (Optic)
  • CN III (Oculomotor)
  • CN IV (Trochlear)
  • CN V (Trigeminal)
  • CN VI (Abducens)
  • CN VII (Facial)
  • CN VIII (Acoustic, Vestibulocochlear)
  • CN IX (Glossopharyngeal)
  • CN X (Vagus)
  • CN XI (Spinal Accessory)
  • CN XII (Hypoglossal)
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19
Q

Physical: Motor Assessment

A
  • inspect and assess muscle mass and tone
  • assess strength and equality between left and right extremities
  • note any abnormalities (atrophy, paresis, plegia, contraction, involuntary movements, spasm, spasticity)
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20
Q

Atrophy

A

decrease in muscle mass

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21
Q

Paresis

A

slight or incomplete paralysis

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22
Q

Plegia

A

complete loss of muscle funcion

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23
Q

Contraction

A

shortening or tightening of the muscles

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24
Q

Involuntary Movements

A

uncontrolled movements

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25
Q

Spasm

A

involuntary muscle contraction

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26
Q

Spasticity

A

increased muscle tone that creates stiff movement

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27
Q

Motor Assessment: Biceps/Triceps

A

grabbing wrists and ask pt to “pull me toward you” and “push me away”

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28
Q

Motor Assessment: Quadriceps

A

ask pt to lift legs against gravity and then resistance

29
Q

Motor Assessment: Plantar Flexion

A

“Step on gas” against hand

30
Q

Motor Assessment: Dorsiflexion

A

“pull toes to nose”

31
Q

Pronator Drift

A

-extend both arms in front of the body
-turn palms upward
-close eyes
>Weak arm: hand pronates and begins to drift downward (positive pronator drift); sign of subtle motor weakness

32
Q

Motor Strength Scale

A

5: Strong, full ROM against gravity and full resistance
4: Slight weakness, full ROM against gravity and moderate resistance
3: Moderate weakness, full ROM against gravity but not resistance
2: Severe weakness, full ROM but w/o gravity or resistance
1: Very Severe weakness, muscle contraction only
0: No movement

33
Q

Physical: Sensory System

A

assessed to determine if the patient can feel or identify specific sensations such as temperature, vibration, superficial or deep pain, proprioception or position sense, and cortical sensory interpretation

  • an advanced practitioner would use a pin, cotton wisp, and tuning fork to determine pain, light touch, and vibration
  • start at feet working upwards
  • pt should be able to distinguish between dull and sharp
  • both sides compared
34
Q

Proprioception

A

patients ability to recognize position w/ eyes closed

  • examiner holds a digit, toe, or finger on the lateral aspect and moves it up or down
  • with eyes closed, pt should be able to tell if the position is up or down
35
Q

Cortical Sensory Interpretation

A

function of the parietal lobe

  • stereognosis
  • graphesthesia
36
Q

Stereognosis

A

ability to identify an object by its shape by simply holding the object
-place a common object (key or coin) in patients hand and ask to identify it

37
Q

Graphesthesia

A

ability to identify letters or numbers when drawn on skin

  • close eyes while examiner draws
  • patient should be able to identify it
  • neglect of or failure to recognize one side of the body may be noted w/ issues in cortical sensory function
38
Q

Abnormalities of the Sensory System

A
  • Anesthesia
  • Hypoesthesia
  • Hyperesthesia
  • Parasthesia
39
Q

Abnormalities of the Sensory System: Anesthesia

A

absence of sensation

-sensations are blocked

40
Q

Abnormalities of the Sensory System: Hypoesthesia

A

decreased sense of touch or sensation

-numbness

41
Q

Abnormalities of the Sensory System: Hyperesthesia

A

increased sensitivity to touch

42
Q

Abnormalities of the Sensory System: Paraesthesia

A

“pins and needles”

-itching, numbness, tingling

43
Q

Cerebellar Assessment

A

evaluating balance, coordination, gait, and posture

-Romberg Test

44
Q

Romberg Test

A

assess balance

  • stand with feet together, arms at the sides, with eyes open; check that patient can do this w/o swaying
  • then asked to close eyes
  • if unable to maintain balance = positive Romberg test; may indicate vestibular or proprioceptive problems
  • a pt w/ cerebellar damage may not be able to balance w/ eyes opened or closed
45
Q

Cerebellar Assessment: Assess Coordination

A

observing:

-basic activities: walking, getting up and down from a chair, or reaching for an object

46
Q

Cerebellar Assessment: Assess Gait and Posture

A
  • should be able to stand and walk erect, with a steady gait

- assess for length of stride, arm movement, base of gait (how far apart feet are placed) and ability to turn steadily

47
Q

Reflexes

A

involuntary and automatic responses to stimuli that provide the body with protection

  • helps to adjust to an ever changing and sometimes dangerous environment
  • reflex arc: occurs when the sensory neurons carry a stimulus to the motor neurons in the spinal cord
  • evaluate major deep tendon reflexes (biceps, triceps, brachioradialis, patellar, Achilles)
  • plantar reflex; Babinski sign
48
Q

The reflex arc

A

occurs when the sensory (afferent) neurons carry a stimulus to the motor neurons in the spinal cord
-motor (efferent) neurons carry the stimulus from the spinal cord to the muscle (a response)

49
Q

Reflex: Babinski Sign

A

practitioner takes the heel of the reflex hammer, or sharp object, and stimulates the outside of the sole of the foot

  • positive sign= toes flare upward; upper motor neuron lesions (damage to the corticospinal tract of the spinal cord)
  • negative= toes flare downward; normal in adults
50
Q

Vital Sign Assessment

A
  • HR, BP, Respirations are regulated in the brain and brainstem
  • changes in VS may develop as a result of alterations in cerebral perfusion, disease, trauma, or swelling
  • VS changes is a late sign of increased ICP or neurological deterioration
51
Q

Increased ICP

A

occurs when there is a disturbance in the balance of volumes within the brain

  • brain tissue, CSF, and blood
  • normal ICP: 0-15 mm Hg
  • increased: > 20 mm Hg
  • show changes in LOC, vomiting, headaches, and seizures
  • Cushing’s Triad: Elevated Systolic BP with widening pulse pressure, bradycardia, and irregular respirations
52
Q

What is a late sign of increased ICP?

A

changes in vital signs

53
Q

Cushing’s Triad for increased ICP

A
  • increased systolic BP w/ widening pulse pressure
  • bradycardia
  • irregular respirations
54
Q

How does Increased ICP Occur?

A

-mass or lesion
-increased volume d/t hemorrhagic event
-increase in CSF d/t blockage or buildup within the CSF drainage system
>the skull is a hard, bony structure w/ no ability to expand

55
Q

Monro-kellie Hypothesis

A

the sum of the volumes of the brain (brain tissue, CSF, and blood) is constant

  • a change or increase in one should create a compensatory decrease in one or both of the other two
  • if the increase in the volume of one of the components exceeds the brains compensatory ability, the intracranial pressure increases = medical emergency
56
Q

Diagnostic Studies

A
  • Computed Tomography (CT)
  • Positron Emission Tomography (PET)
  • Magnetic Resonance Imaging (MRI)
  • Magnetic Resonance Angiography (MRA)
  • Cerebral Angiography
  • Computed Tomography Angiography (CTA)
  • Electroencephalography (EEG)
  • Lumbar Puncture (LP)
  • Myelography/ myelogram
  • Brain biopsies
57
Q

Diagnostic Studies: Computed Tomography (CT)

A

cross-sectional images that are viewed as cuts or slices

  • allows views of the brain and spine
  • orbits in a quick, noninvasive manner
  • used to assess for bleeding, edema, or masses
58
Q

Diagnostic Studies: Positron Emission Tomography (PET)

A
  • administration of the radioactive glucose tracer fluorodeoxyglucose (FDG)
  • detects areas of increased metabolic activity in the body
59
Q

Diagnostic Studies: Magnetic Resonance Imaging (MRI)

A
  • noninvasive
  • uses magnetic fields to obtain images
  • provides three-dimensional images
  • offers clear visualization and detail of small structures
60
Q

Diagnostic Studies: Magnetic Resonance Angiography (MRA)

A

type of MRI that uses radio-wave signal characteristics of flowing blood to get images of the body’s blood vessels

  • looks at blood flow in the vessels
  • determines the presence of aneurysms, clots, dissections, or vessel stenosis
  • performed the same as an MRI
61
Q

Diagnostic Studies: Cerebral Angiography

A
  • invasive
  • intra-arterial (inserted in an artery; femoral)
  • radiological procedure
  • looks at blood flow in the vessels
  • involves administration of radiopaque dye through a catheter
62
Q

Diagnostic Studies: Computed Tomography Angiography (CTA)

A

combines the technology of a CT scan (cross-sectional images of the brain) and traditional cerebral angiography (enhanced visualization of cerebral vasculature through the IV injection of contrast dye)
-evaluates cerebral vasculature

63
Q

Diagnostic Studies: Evoked Potential

A
  • painless
  • noninvasive
  • measures the speed and size of nerve conduction generated by the nervous system in response to stimuli
  • electrodes are attached to the scalp and to different areas on the body depending on type of test being conducted
64
Q

Diagnostic Studies: Lumbar Puncture

A

most common procedure done to obtain a sample of cerebrospinal fluid (CSF) for analysis and to measure intracranial pressure

  • increased pressure may = CSF obstruction or overproduction
  • can be done at beside
  • CSF should be clear, and contains glucose and protein
  • traces of RBC may be related to the puncture done for the test
  • post-procedure: flat bedrest 4-6 hours; hydration
  • headache post-procedure = leakage of CSF and may require a blood patch
65
Q

Diagnostic Studies: Myelography/myelogram

A
  • invasive radiographic procedure
  • involves lumbar puncture and injection of contrast medium into the subarachnoid space around the spinal cord
  • x-rays are taken that enable visualization of the entire spinal column
  • evaluates for lesions, cysts, injury, herniated discs, and masses/tumors
66
Q

Diagnostic Studies: Biopsy

A
  • invasive
  • done to obtain tissue samples for examination
  • indicated to r/o or identify infections or abscesses
  • used to identify tumor tissue
  • types: needle, stereotactic, and open
67
Q

Positioning for a Lumbar Puncture

A
  • can be done at bedside
  • CSF should be clear, and contains glucose and protein
  • Traces of RBC may be r/t the puncture done for the test
  • post-procedure: Flat bedrest 4-6 hours; hydration
  • headache post-procedure = leakage of CSF and may require blood patch
  • patient lays on side with shoulders vertical (–) or
  • patient sits on the edge of the bed, head down, leaning forward over a bedside table
68
Q

Age-related Changes

A
  • motor changes, sensory changes, and altered thermoregulation
  • changes can be subtle and occur over time
  • changes in CNS occur as the brain weight and mass decline w/ a loss of neurons
  • gerontological changes: slowed body movements, decreased reaction time, decreased muscle strength and flexibility, decreased smell, decreased temperature, decreased touch, decreasing neurosensory function
  • pain sensations can be decreased
  • slower cognitive processing
69
Q

Diagnostic Studies: Electroencephalogram (EEG)

A

records electrical activity in different regions of the cerebral cortex

  • used for seizure activity
  • used to identify areas of abnormal wave patterns indicating brain tissue dysfunction
  • continuous EEG used to detect seizure activity and status epilepticus
  • used as a test to confirm cessation of electrical activity in the brain when brain death is suspected
  • neurologist provides official reading of EEG

Nursing 272: Final Semester (79 decks)

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