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Chp. 44 Med-Surg I
Assessment of the Nervous System pg. 922 III
| Question | Answer |
|---|---|
| Touch | Touch discrimination: client closes eyes, practitioner touches him or her with finger and client points where they were touched |
| Abnormal Sesnory Findings | Porprioception: Position sense (knowing where your limbs are positioned)Contralateral: opposite side of body ex: problems in the brainsteam, thalamus, and cortex result in loss of sensation on the opposite side of body |
| Assessment of Motor Function | asking ct to grab and squeeze two fingers of each of your hands, or test strength against your resistance |
| Cerbera/brainsteam integrity | ask ct to close eyes and hold arms perpendicular to the body palms up for 15 to 30 sec, cerebral or brainsteam reason for weakness arm on weak side will start to fall "pronator drift" |
| Assessment of Cerebellar functionCoordination | Ct sits on side of bed, runs the heel of one foot down the shin of the other leg and repeat with the other leg or slap hands quickly on their thigh or touch finger to nose |
| Gait and Equilibrium | ask ct to walk across room and return, observe inequlity in steps and balance. to check equilibrium ask ct to stand w/arms at sides, feet and knees close together, eyes open, then closed; ct sways w/eyes closed positive Romberg sign |
| Gait and Equilibrium | sways w/ eyes open and closed Cerebllar neurologic disturbance |
| Assessment of Reflex activity Deep Tendon Reflexes | Appropriate muscle contraction indicates intact reflex arc. Babinski's sign toes fan out, should not occur after the age of 2 |
| Abnormal Reflex Findings Clonus | sudden brief, jerking contraction of a muscle or muscle group seen in seizures |
| Rapid Neurologic Assessment Ct is admitted to a health care facility on an emergent basis, routine assessment, or sudden change in neurologic status | Gasgow coma scale: most reliable neuro assessment; establishes baseline data in eye opening, motor response, and verbal responseScore of 15 represents normal functioning, 3=deep coma state |
| Response to Painful Stimuli Apply painful stimuli | supraobital pressuretrapezius squeezemandibualr pressuresternal rub |
| Level of Consciousnes Decorticate posturing and | Decorticate Posturing Think (Down and In)seen in clients with lesios that interrup the corticospinal pathways; arms, wrists, and fingers are flexed with internal rotation, planter flexation of legs |
| Decerebate posturing | Decerebate Posturing Think (Down and Out) associated w/ brainstem dysfunction; rigidity extension of arms and legs, pronation of arms, planter flexion, and opisthotonos |
| Pupil assessment PERRLA | Pupils Equal in SizeRound, Reactive to Light and Accomodation Shine light in eye 4-5 inches away from noses and one pupil constricts(Direct Response) the other eye constricts slightly (Consensual response) |
| Radiographic Examinations; X-Ray of Skill and Spine | used to determine bony fractures, curvatures, bone erosin, bone dislocation and calcification of soft tissue (all can damage nervous system) |
| Cerebral Angiography (arteriography) | to visualize cerebral circulation (carotid and vertebral arteries)1. contrast medium injected inot an artery (femoral)to identify aneurysms, traumatic injuries, strictures/occlusions, tumors, and arteriovenous malformations |
| Client Preparation for Cerebral Angiography | 1. determine if ct is allegic to iodinated contrast agent2. porcedure explained to ct by person who obtains written consent (radiologist)They understand if they know they cannot:move during procedureimmobilzation of headNPO 4-6 hrs before test |
| Client Preparation for Cerebral Angiography | no hairpins or jewelryrecord neourologic and vital signsempty bladder before procedure |
| Computed tomography CT scanning | quickest, easiest, least expensive method of diagnosing neurolgoic problems. |
| Magnetic Resonance Imaging MRI | produces images superior to CT scan, no ionizing radiation only magnetic fieldscontraindicated for clients w/ cardiac pracemakers, and other pumps and stents |
| Lumbar Puncture (Spinal tap) | insertion of a spinal needle into the subaracnoid space between the third and fourth lumbar vertebrae |
| Lumbar Puncture (Spinal tap) | used to:1. pressure readings w/ manometer CSF analysis spinal blockage attributable to a spinal cord lesion inject contrast medium of air ; reduce mild to moderate increased intracranial pressure |
| Lumbar Puncture (Spinal tap) Client Prep | 1. signed consent 2. explaination of procedure 3. some cts experience pain in leg when spinal needle is injected4. ask ct to empty bladder5. on either side that is comfortable for ct, close to edge of bed with knees to chest "fetal position" |
| Lumbar Puncture (Spinal tap) Procedure | CONTRAINDICATED IN CT W/ INCREASED INTRACRANIAL PRESSURE, instruct ct to report any shooting pain or tingling sensation; 3 -5 test tubes obtained |
| Lumbar Puncture (Spinal tap) follow up care | ct restricted to bedrest for 4-8 hrs in flat position, prevents CSF leakage; increase fluid intake to 3000mL for 24-48 hrs to facilitate in CSF production; decrease in CSF may cause severe headache; frequent neuro checks |
| Electorencephalography (EEG) | records electrical activity of cerebral hemispheres; test performed to determine activity of hemespheres; orgin of seizure activity; tumors, abscesses, cerebrovascular disease, hematomas, injury, drug intoxication; sleep disorders |
| Electorencephalography (EEG) Client Prep | Ct is sleep deprived, or should be awake from 2-3am thru the rest of the night; CNS depressants and stimulants are not given before the test |
| Electorencephalography (EEG) Client Prep | If anticonvulsants are withheld, monitor for seizure activity; ct should avoid coffee, tea, and other stimulants; they CAN eat! |
Created by:
prettydee1908
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