Week 8 - Assessment Flashcards
(222 cards)
1
Q
define Munroe Kellie Doctrine
A
- as one volume of the brain increases, the volume of another must decrease
2
Q
define ICP
A
- pressure exerted bc of the combined total volume of 3 components within the skull
3
Q
what is an early indicator of neurological status
A
- LOC
4
Q
define cushing’s triad
A
manifestations that causes:
- increased systolic BP
- decreased HR
- decreased RR
5
Q
compression of which nerve causes dilated & fixed pupils
A
- CN 3 = oculomotor
6
Q
define decorticate
A
- position resulting in internal rotation & adduction of arms
- w flexion of the elbows, wrists, and fingers
7
Q
define decerebrate
A
- position resulting in arms stiffly extended, adducted, and hyperpronated
- legs hyperextended with plantar flexion of the feet
8
Q
define herniation
A
- protrusion of brain tissue thru one of the rigid intracranial barriers resulting from increased ICP
9
Q
list 3 intracranial barriers brain tissue may pass thru during herniation
A
- foramen magnum
- tentorial notch
- falx cerebri
10
Q
when should neuro status be checked (6)
A
- on admission
- baseline (start of shift)
- loss of consciousness
- any changes in behavior or status
- if there is a neuro specific admission or e/c
- after a fall
11
Q
what mneomic is used to collect health history?
A
A: age, allergies M: medication P: past medical, family, and surgical history L: lifestyle E: entrance complaint
12
Q
what are the 6 components of a neuro exam
A
- mental status
- sensory exam
- cranial nerves
- cerebellar/coordination
- motor exam
- reflexes
13
Q
how can we assess a pt’s mental status (5)
A
- general appearance or behavior
- LOC
- cognition (orientation)
- mood & affect
- thought content (ex. hallucinations)
14
Q
define mood
A
- the emotional state that the pt tells you they feel
15
Q
define affect
A
- the emotional state we observe
16
Q
what are some additional questions to ask the pt
A
- ADLs
- nutritional status
- bowel & bladder status
- motor problems
- sleep problems
- relationship & sexual problems
17
Q
what are cranial nerves? how many do we have?
A
- nerves responsible for our sensation & movement
- 12 pairs
18
Q
cranial nerves can be..
A
- sensory
- motor
- or both
19
Q
list the 12 pairs of cranial nerves
A
Olfactory Optic Oculomotor Trochlear Ttrigeminal Abducens Facial Vestibulocochlear Glossopharyngeal Vagus Accessory Hypoglossal
20
Q
which cranial nerves are sensory vs motor? (dont need to know but i find it helpful to remember what each one does)
A
Some Say Marry Money But (both) My Brother Says Big Brains Matter More
21
Q
what is CN 1? what type of nerve? and how do we assess it
A
olfactory –> involved in sense of smell = sensory
- ask if they have had any changes in smell
- assess if nostrils are patent (unobstructed)
- test with a known odour
22
Q
describe how to do an odour test for CN1; what is commonly used for it
A
- have pt close eyes & plug 1 nostril
- get them to smell the object for both sides
- common smell used is vanilla
23
Q
what is a common brain/head injury that results in loss of smell
A
- skull fracture (esp. basilar)
24
Q
what is CN 2? what type? what is it involved in?
A
- optic
- sense of vision = sensory
25
what 3 ways can we assess the optic nerve
- visual fields (peripheral)
- optic nerve
- visual acuity
26
what is visual acuity? how is it tested
- the sharpness or clearness of vision
| - uses the Snellen eye chart
27
what is peripheral vision
- everything you see off to the side of your central focus while looking straight ahead
28
how is peripheral vision testes
- getting the pt to cover one eye while you also cover your eye
- place a stimulus (certain # of a fingers up) within different edges of the visual field while they look straight ahead
29
what is it called if a large part of their visual field is missing? what can cause this?
- hemianopia
| - damage to the optic nerve
30
what 3 CN play a role in the movement of the eye
- 3, 4, 6 (oculomotor, trochlear, and abducens)
31
what is CN 3? what type of nerve? what is CN 3 specifically responsible for (3)
oculomotor --> motor
- eyelid opening
- pupil response to light (constriction)
- movement of the eye
32
what is a droopy eyelid called
ptosis
33
what abnormalities should we look for when assessing CN 3`
- dilated pupils
| - ptosis
34
what is the connection between ICP and CN3`
- increased ICP may put pressure on CN 3
| = causing pupils to dilate & become fixed (not respond to light)
35
what should we assess regarding CN 3,4, and 6 (6)
- extraocular movements (eye movement)
- 6 cardinal positions of gaze
- corneal light reflex
- nystagmus
- ptosis
- convergence & accomodation
36
what do we look for during corneal light reflex
- do both pupils restrict and restrict equally?
| - was it brisk, sluggish, or fixed
37
how do we assess the 6 cardinal positions of gaze
- draw an H or star with fingers
| - tell the pt to not move their head, and follow your finger w their eyes
38
what do we look for during assessment of the 6 cardinal positions of gaze
- are both eyes moving together & at the same time? any nystagmus?
39
what is nystagmus
- uncontrolled, shaking movement of the eye
40
how do we test for convergence?
- take a finger, tell the pt to look at it, and bring the object inwards to their nose
41
what is normal vs abnormal movement findings during a convergence test
- normal = both eyes simultaneously move inwards toward each other (like cross eyed) to look at a close object
- convergence insuffieniency = causes one eye to drift outward
42
what is accommodation of the eye
- a reflex that changes the structure of the lens so you can see both near & far
43
how do we assess accommodation of the eye
- get them to look at one thing close such as your finger
- then the wall
i think (??)
44
what is considered normal during assessment of accommodation
- pupils should dilate when looking at something far away & constrict when looking at something close
45
what is cranial nerve 4? what does it do? what type of nerve?
- trochlear --> motor
| - one of the ocular motor nerve that controls eye movement --> down & in
46
what is CN 5? what does it do? what type of nerve?
- trigeminal
- sensory & motor =
- plays role in sensation of the face
- motor fnxn = opening & closing jaw (biting, chewing)
47
how do we assess the motor function of CN5
- get the pt to clench their teeth
- palpate the temporal & masseter muscle
- try to push on chin to open
48
how do we assess the sensory function of CN 5
- provide light touch to the forehead, cheeks, and chin using a cotton ball & ask them to close their eyes & say when you touch their face
- assess any pain
49
what is CN 6 & what is its function? what type of nerve?
- abducens
- motor
- role in eye movement --> turns eye outwards
50
what is CN 7? what type of nerve? what is its function?
- facial nerve
- sensory & motor
- motor = facial expression & mobility & symmetry
- sensation = part of the tongue (taste)
51
how do we assess cranial nerve 7
- ask to raise eyebrows, smile, frown, show teeth, puff cheek
- ask to close eyes tight and not let you open them
52
which pts might have trouble with the assessment of CN 7
- stroke pt
| - facial palsy pt
53
what is CN 8? what type of nerve? what does it do?
- vestibulocochlear
- sensory
- sense of hearing & balance
54
how do we assess CN 8
- thru normal convo
- ask if there has been any changes to hearing
- whisper voice test
55
describe how to do the whisper test
- plug one of the pt's ears
| - then whisper something into the ear (at a short distance away)
56
what is CN 9? what type of nerve? what does it do?
- glosspharyngeal
- sensory & motor
- motor = swallowing, salivation
- sensory = tongue (taste), gag
57
what is CN 10? what type of nerve? what does it do?
- vagus
- sensory & motor
- motor = swallowing, talking
58
how do assess CN 9 & 10
- ask pt to swallow & cough
- test gag reflex
- ask them open their mouth wide and say "ahh"
59
what should you expect to see when asking a pt to open mouth and say "ah"
soft palate & uvula should rise to midline
60
what are the gag, cough, and swallow reflexes often known as? why?
- protective reflexes
| - prevent aspiration & choking
61
what is CN 11? what type of nerve? what does it do?
- spinal accessory
- motor
- movement of shoulders, neck, & head
62
how do we assess CN 11?
- shrug shoulders against resistance
- assess neck muscles
- look for symmetry
63
what is CN 12? what type of nerve? what does it do?
- hypoglossal
- motor
- tongue movement
64
how do we assess CN 12?
- ask them to stick out their tongue midline, & move side to side
- ask them to pronounce "light, tight, dynamite"
65
what is the function of the cerebellum
- coordination
| - balance
66
how do we assess cerebellar function (4)
- romberg test
- heel to toe test
- rapid alternating finger movements
- rapid alternating hand movements (such as flipping hand over)
67
what does reflex testing tell us?
- reveals intactness of reflex arc
68
what should we assess during reflex testing
- compare L&R
| - grade on scale of 0-4
69
what does each level of the reflex grading scale mean?
```
4 = hyperactive
3= brisker than nomr
2 = avergae
1 = diminished
0 = no response
```
70
how do we assess plantar reflex
- stroke lightly up latersal side of sole of foot & inward across ball of foot (make a J)
71
what is considered a normal plantar reflex? what is abnormal and what is this called?
- normal = flexion of toes & inversion and flexion of forefoot
- abnormal = toes fan out = babinski sign
72
when do we do an acute neuro assessment?
- for pts with acute neuro issues who need frequent monitoring & assessment for changes
73
what does an acute neuro check look like?
- does not include all components of a neuro assessment
| - must be timely & efficient esp if they have a fluctuating status
74
what is included in neuro check or "neuro vitals" (6)
- LOC
- orientation
- VS
- motor function/abnormal posturing
- pupillary response
- protective reflexes
75
what protective reflexes are assessed during a neuro check (4)
- gag
- swallow
- cough
- blink
76
what is the most common neuro assessment tool
glasgow coma scale
77
why is the GCS used>
- to monitor trends in LOC
- influences treatment & decision making
- universally used
78
what should you check prior to complete a gcs score
- check for any factor that may interfere w the assessment
79
what are the 4 steps to completing a gcs assessment
1. check
2. observe
3. stimulate (if required)
4. rate
80
what does a GCS score of 13-15 mean
- mild injury
81
what does a GCS score of 9-12 mean
moderate injury
82
what does a GCS score of less than 8 mean
- severe injury
83
what does a GCS of 3 mean
- totally unresponsive
84
what are 3 sites for physical stimulation during GCS assessment
- finger tip pressure
- trapezius pinch
- supraorbital notch
85
what 3 things are assessed on the GCS
- eye opening
- motor response
- verbal response
86
what does each rating of the GCS mean regarding eye movement
- open spontaneously = 4
- open to voice = 3
- open to painful stimuli = 2
- no response = 1
- non testable
87
what does it mean if a pts eye response is non testable
- eye swelling or any other physical obstruction prevents the pt from being able to open the eye
88
what responses are assessed regarding verbal response
- orientated x 3 = 5
- confused = 4
- inappropriate words = 3
- incomprehendible sounds ( moans, etc.)= 2
- no response = 1
- non testable
89
what is meant by the confused response when assessing verbal response
- pt communicates coherently but not orientated
| ex. facts are wrong
90
what is meant by the inappropriate words response when assessing verbal response
- communicating single words but they do not make sense
91
what may cause a pt to be nontestable when assessing verbal response
- breathing tube
| - NG tube
92
what responses do we assessing when assess motor response of GCS
- obeys commands = 6
- localizes = 5
- withdraws = 4
- abnormal flexion (decorticate) = 3
- abnormal extension (decerebrate) = 2
- none = 1
93
what is meant by a "localizes" response when assessing motor response
- brings hand toward painful stimulus
94
what is meant by a withdraws response when assessing motor response
- pulls away from painful stimlus
95
what is abnormal flexion
- decorticate
| - bends arm at elbow
96
what is abnormal extension
- decerebrate
| - extends arm at elbow
97
what vital signs are imp to assess during neuro assessment
- BP
- HR
- RR
- temp
98
what changes in BP might you see during a neuro assessment? why?
- increased systolic BP
- increased ICP causing decreased O2 to the brain & the body reacts by increasing BP to try and get more blood to the brain
99
what changes in temp might you see during a neuro assessment ? why?
- increase in temo
| - if any damage to the hypothalamus
100
what changes in RR might you see during a neuro assessment? why?
- decreased & cheyne stokes respirations
| - due to pressure on the brainstem causing depression of the medullary resp. center
101
what changes in HR might you see during neuro assessment? why?
- decreased HR
| - increased BP triggers baroreceptors which decrease HR
102
what acronym is used for pupillary response
PERRLA
103
what does PERRLA stand for
pupils equal, round, reactive to light, accomodation
104
what cranial nerve is responsible for pupillary response?
- CN 3
105
describe how to assess pupillary response
- measure pupil size before & after shining light
| - note the response: brisk, sluggish, or incomplete
106
what is mydriasis
- abnormal pupil dilation
| - can be uni or bilateral
107
what is miosis
- abnormal constriction of pupil
| - can be uni or bilateral
108
what is normal pupil size
between 2 - 4
109
where do we assess motor function
- upper & lower limbs
110
describe how to assess the upper limbs (2)
- hand grasps (bilat at the same time)
| - assess palmar drift
111
what is palmar drift
- tell pt to close their eyes & put their hands on
| - watch to see if one side drifts down
112
what does palmar drift assess for
- stroke
113
how do we assess lower limbs for motor function? (2)
- push pedals (bilat at the same time)
| - leg drift
114
what 2 types of posturing do we want to assess for? which is "better" and which is worse
- decorticate = slightly better
| - decerebrate
115
what are the 3 protective reflexes
- cough
- gag
- swallow
116
what do the protective reflexes protect against
- aspiration
117
what cranial nerve are involved in the protective reflexes
9 and 10
118
excitaroy neurons release the nt
glutamate
119
inhibitory neurons release the nt
- GABA
120
true or false, a pt experiencing a tonic-clonic seizure is experiencing a focal seizure
- false
121
what is an absence seizure
- seizure common in children
- often looks like they are "daydreaming" or staring into space
- lasts about 10 secs and occurs multiple times throughout the day
122
describe what we should ask about regarding PMHx during a seizure assessment
- neuro diseases
- head trauma
- infection
- perinatal history
- hypoglycemia
- electrolyte imbalances
- anything causing hypoxia
123
what should we ask regarding FHx when doing a seizure assessment
-family history of seizure disorders?
124
what should we ask regarding lifestyle during a seizure assessment
- drug use
- risk taking behaviors
- contact sports
125
what are the 2 types of seizures
- generalized
| - focal
126
what is a generalized seizure
- one that effects both sides of the brain
| - bilateral synchronous epileptic discharges in the brain
127
what are 6 types of generalized seizures
- absence
- tonic-clonic
- atonic
- clonic
- tonic
- myoclonic
128
what is an absence seziures? who is it common in?
- brief starring spell that only lasts a few seconds
| - mostly in kids
129
what is a myoclonic seizure
- sudden excessive jerking of body & extremities
130
what is a tonic seizure
- sudden onset of maintained increased muscle tone (stiffening) in the extensor muscles
- usually causes the pt to fall
131
what is a clonic seizure
- loss of conciousness
| - sudden loss of muscle tone followed by limb jerking
132
what is an atonic seizure
- "drop attack"
| - tonic episode or paraoxysmal loss of muscle tone that begins with person falling to the ground
133
what is a tonic-clonic seizure
- periods of tonic phases (stiffening)
| - followed by period of clonic phase (jerking of extremities)
134
what is a focal seizure
- seizure that begins in one hemi
135
what are 2 types of focal seizures
1. simple
| 2. complex
136
what is a simple focal seizures
- where the person remains conscious
| ex. sudden unexplained feelings, nausea
137
what is a complex focal seizure
- change or loss of LOC
| ex. lipsmacking, automatisms
138
what are 2 nursing priorities for tonic clonic seizures
- airway
| - safety (particularly the head)
139
define status epilecticus (2)
- 2+ seizures in 5 minutes
| - when a seizure goes on or longer than 5 min
140
what are the consequences of status epilecticus (3)
- hypoglycemia
- acidosis
- loss of airway
141
the nurse is caring for a pt who has been seizing for 5 min. the most appropiate med to administer is??
lorazepam
142
why would you choose lorazpem over diazepam
- lasts longer in the system & is the go to drug for status epilepticus
143
what should you take note of during nursing assessment of seizures
- antecedent events
- precipitating factors
- time it started & length of tie
- postictal stages
- vital signs
- posturing & movements
144
what diagnostics are done for seizures
- comprehensive history & physical
- seizure history
- blood work
- ct, mri
- EEG
145
what should we note regarding seizure history
- what happened before
| - seizure event description
146
what should we assess for blood work r/t seizures
- Na
- Ca
- blood glucose
147
what is an EEG
electroencephalogram
148
how do drugs prevent seizures?
- by preventing the excitation of neurons
149
what are 5 main MOAs of AED
- suppress Na influx
- suppress Ca influx
- promote K eflux
- antagonize glutamate
- potentiate GABA
150
what do most AED require monitoring of? why?
- plasma drug lvl monitoring
| - to help control seizures quickly
151
describe pt adherence for AEDs
- requires continuous & regular therapy
152
describe the withdrawal of AEDs
- must be withdrawn slowly
| - otherwise they could experience withdrawal, rebound seizures, or statis epilepticus
153
what does epilepsy & AEDs carry a risk of for all pts? how does this affect our monitoring?
- depression
| - monitor for anziety, agitation, depression, and suicidal ideation
154
what do several AEDs decrease the effectiveness of
- birth control pills
155
can AEDs be used if the pt is pregnant? why or why not?
- no
| - they are teratogenic = harmful to the fetus
156
what is the MOA of valproic acid (3)
- suppresses Na influx
- suppresses Ca influx
- augment the inhibitory influence of GABA
157
what is valproic acid used for
- all major seizure types
158
describe side effects of valproic acid (2)
- few side effects
| - NV (take w food)
159
what are 2 contraindications for valproic acid?
- metabolized by the liver = be careful for pts w liver disease
- highly teratogenic
160
what pt education should be provided for valproic acid since it is highly teratogenic
- must take folic acid supplements
161
what is phenobarbital
- barbituate used for seizures
162
what is the MOA of phenobarbital
- potentiates the effects of GABA
163
describe the side effects of phenobarbital (5)
- lots of side effects
- drowsiness
- sedation
- physical dependence
- decrease synthesis of vit K = risk of bleeding
164
what types of seizures is phenobarbital used for
- partial & generalized
| - NOT for absence
165
what are some contraindications for phenobarbital (2)
- teratogenic
| - avoid taking w other CNS depressants
166
what is a benefit to phenobarbital
- long half life
167
what is lorazepam
- a type of benzo
168
what is the MOA of lorazepam
- potentiates the effects of GABA
169
what is lorazepam used for
- status epilepticus & acute seizures
170
describe the side effects of lorazepam (3)
- drowsiness
- sedation
- physical dependence (not as much as phenobarbital)
171
what is 1 contraindication for lorazepam
- avoid taking w other CNS depressants
172
what is keppra
- AED with unknown MOA
173
describe the side effects of Keppra (3)
- drowsiness
- weakness
- does not impact congition or focus
174
what is 1 contraindication for Keppra
- can cause kidney injury
175
describe the interaction between Keppa and other drugs
- does not interact
| - does not effect birth control effectiveness
176
what is phenytoin
- a type of hydantoin
177
what is the MOA of phenytoin
- suppresses action potentials thru inhibiting Na channels
178
what is phenytoin used for
- all major forms of epilepsy
- NOT for absence
- especially effective against tonic-clonic
179
describe plasma levels of phenytoin
- very sensitive
- small changes in dosage above the therapeutic range can cause toxicity
= narrow therpeutic range
180
list side effects of phenytoin (6)
- nystagmus
- sedation
- ataxia
- diplopia
- cognitive impairment
- gingival hyperplasia
181
what are 2 contraindications / interactions for phenytoin
- teratogenic
| - can decrease vit K dependent clotting factors
182
what can administering phenytoin via IV cause (3)
- dysrhythmias
- hypotension
- "purple glove syndrome"
183
what are 3 important things to note for adminstering phenytoin IV
- inject slowly
- dilute w saline
- never mix with dextrose solutions (will precipitate and destroy the vein)
184
what kind of IV do you want to use for phenytoin? why?
- central line or large peripheral IV
| - can cause extravasation
185
what 2 drugs increase phenytoin lvls in the blood
- diazepam
| - valproic acid
186
what 3 things can reduce phenytoin levels in the blood
- carbamazepine
- phenobarbital
- alcohol
187
what is the MOA of topiramate (4)
- potentiates the effects of GABA
- blocks sodium channels
- block calcium channels
- blocks glutamate receptors
188
describe the side effects of topiramate (5)
- few
- fatigue
- difficulty conc
- weight loss
- depression
189
what does topiramate have a higher risk of versus other AEDs
- higher risk of suicide
190
what is a contraindication of topiramate
- if pts have kidney disease
191
what is gabapentin
- an adjunctive therapy for seizures
192
what is the MOA of gabapentin
- GABA analog
193
describe side effects of gabapentin (4)
- mild to mod
- drowsy
- dizziness
- considered v safe
194
what is 1 contraindication w gabapentin
- elderly pts eliminate the drug more slowly & more suspectible to side effects
= greater risk of falls
195
describe interactions w gabapentin
- does not interact w other med
196
what is the MOA of carbamazepine
- suppression of sodium channels (and therefore delays the activation)
197
describe side effects of carbamazepine
- minimal effect on cognitive function
| - bone marrow suppression
198
what are contraindications of carbamazepine
- should not be taken w grapefruit (effects how it works)
- should not be given to pts with pre-existing hematologic disorders
- teratogenic
199
what should you monitor for a pt on carbamazepine
- CBC
| - for leukopenia, anemia, and thrombocytopenia
200
what do you need to safely care for a pt at risk of seizure?
- lorazepam
- BG monitor
- pillow
- suction
- hand sanitizer
- padding for side rails
- pen & paper to document
201
what are ur assessment priorities for acute neuro assessment
- airway
- breathing
- circulation
- VS
- LOC
- orientation
- pupils
- protective reflexes
- motor
- other signs of trauma (leaking CSF, bruising)
see notes for more info on why
202
what does battle signs bruising & raccoon eye bruising often occur with?
- basilar skull fracture
203
what else should you monitor for with a basilar fracture
- leakage of CSF or blood
204
what are 2 indicators of CSF
- will be positive for glucose
| - halo sign
205
what 2 meds can be used to decrease ICP
- mannitol
| - diuretic
206
what is mannitol
- an osmotic diuretic
207
how do you assess the protective reflexes
- ask them to swallow
- ask them to cough
- can use a tongue depressor or oral suction to elicit a gag
208
what are the indications for mannitol
- treatment of elevated ICP
- edema
- increased intraocular pressure
- oliguric renal failure
209
what is the MOA of mannitol
- inhibits reabsorption of water & lytes
| - pulls water out of the brain
210
how is mannitol best used
- by bolus administration where an acute reduction in ICP is required
211
what occurs immediately after bolus admin of mannitol
- circulating volume increases
| = decreased blood viscosity & increased cerebral blood flow & O2 delivery
212
how long does it take for mannitol's osmotic properties to take effects
- 15-30 min
| - when it sets up an osmotic gradient and draws water out of neurons
213
how is mannitol excreted? what does this mean
- urine
| = increased serum & urine osmolality
214
how can hypovolemia be avoided with mannitol
- the infusion of isotonic fluids
215
what is an epidural hematoma
- bleeding between the dura mater & inner surface of the skull
216
what is a subdural hematoma
- bleeding between the dura mater & arachnoid mater
217
what is a intracerebral hematoma
- bleeding within the brain itself
218
true or false; compression of cranial nerve will affect constriction of the pupils
- true
219
true or false; decerebrate posturing is more serious than decorticate
true
220
true or false; a CT scan is the most appropriate diagnostic test for diffuse injuries such as diffuse axonal injuries
false
221
during an assessment, the pt suddenly stares off, body begins to stiffen, lost consciousness, and then his arms and legs start jerking
what is happening
tonic clonic seizure
222
what drug can cause gum changes
- phenytoin
