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Neuro 260

Neuro Clinical Topics: Neuro Assessment Tool

QuestionAnswer
The Glasgow Coma scale is a 15 point scale that is used to measure neurological status, what does it measure responses to? Eyes Open, Best Verbal Response, Best Motor Response
What are the different point values given for the different Eyes Open responses? Spontaneously - 4, To Speech - 3, To Pain - 2, None - 1
What are the different point values given for the different verbal responses on the Glasgow Coma Scale? Oriented - 5, Confused - 4, Inappropriate Words - 3, Incomprehensible Sounds - 2, None - 1
What are the different point values given for the different Best Motor Responses on the Glasgow Coma Scale? Obeys commands - 6, Localize Pain - 5, Flexion Withdrawal - 4, Abnormal Flexion - 3, Abnormal Extension - 2, Flaccid - 1
Patients with Glasgow Coma Scales of _____ or below are in very poor shape. 8
Glasgow Coma Scales of _____ to _____ usually are comatose patients and there is a very high potential that they will remain in a permanent vegetative state. 3 to 6
Sometimes you will see _______ responses from geriatric patients, the dementia patients, and the alzheimers patients where the answer to everything might be "NO" or "my shoes". Automatistic
In patients displaying automatistic cognitive functioning why is the answer to everything "NO"? It is because they are not able to cognitively process the information because they have a breaking down of the neuro system.(similar to an immature system)
For our brains to do math, what does it require? A higher level of functioning.
A person can lower their stress by focusing on what? A much higher functioning part of your brain.
When evaluating Alzheimer's patients we must remember that they are very good at doing what? Hiding that they don't remember things.
Women in menopause will experience a short term memory loss which is not neurologically related, instead it is related to what? Flucuation of hormones. It is normal in menopause.
When you have a patient that has a neurological disorder a change in affect(mood) occurs. Why? Because of a void or empty space that the response runs into causing changes/inappropriate responses.
Parkinsons patients tend to develop a very _____ affect. flat
What needs to be communicated to patients and family about the patients affect? They cannot control their behavior, it is part of the disease process.
When we look at thought content, what do we want to look at? All the psych issues, delusional paranoia, obsessed with one idea, and appropriate and intact behavior.
If you are doing a neuro assessment and it doesn't quite feel right, what should you do as a nurse? You need to continue to probe.
Changes in speech can ___ and ____. Why? come and go, fatigue and stress will exacerbate a neuro problem and it takes alot of damage before these symptoms are cosistent.
Describe what a person with Wernicke's aphasia would have difficulty doing. They have compresion difficulties, and usually little difficulty talking. Example: A person may call a knife a gleeble.
Describe Broca's aphasia. Difficulty with forming complete sentences and the rules of grammar. People with Broca's aphasia often speak in short sentences like, "walk home".
Describe the patient with Global aphasia. These patients can barely speak or understand what is being said to them. In addition, they can no longer read or write.
What nerve has to do with the sense of smell? Cranial nerve 1 - Olafactory
The location of the the olfactory nerve causes the nerve to be ________ easily. damaged
Many persons that have experienced a significant trauma may not have a Sense of smell, they may never get it back, but they may also get some of it back.
What nerve has to do with vision? Cranial nerve 2 - Optic
What do we do to check function of the optic nerve? Field of vision, visual acuity and structures (external, internal, red reflex and optic disc.)
What nerve has to do with the eyelids? Cranial nerve 3 - Occulomotor
What cranial nerve is responsible for facial sensations and clenched jaws? Cranial nerve 5 - Trigeminal
When doing a corneal reflex, we need to remember what key factor? Age slows down the reflex. Contact lenses can effect the corneal reflex as well.
Blue eyed people will have larger pupils than people with dark eyes. Why? Because people with blue eyes will let more light in.
Cranial nerves 3,4,5, and 6 have to do with what? The eyes.
Cranial nerve 7 comes out of the temple and runs all the way down to the corner of the mouth. Ifthere are problems with this nerve, what might we see? Drooping of the corner of the mouth (Bell's Palsy)
Sometimes you can see Bell's Palsy follow what event? Childbirth
How long does Bell's Palsy tend to last? 12-14 days
Persons with Bell's Palsy normally do not have any _____ effects once it is gone. residual
What is the 8th cranial nerve responsible for? Acoustic
When we look at the 9th and 10th cranial nerves, what is important to look at? Gag reflex, swallowing, uvula symmetry, phonation, taste.
A patient with uvula symmetry will develop an inability to do what? Projecting their voice.
The longest nerve in your body is the vagus nerve
Why is it important to watch the HR when a person is being intubated? They can vasovagal down very quickly with just the stimulation from the laryngealscope.
Cranial nerve 11 involves what area? Neck and shoulder movement.
When a person has a stroke and their cranial nerve 12 is affected, what will we see? The persons tongue will protrude from the mouth.
What is cerebellar functioning? It is coordination. Rapid altenating movements. It controls your movements.
As a disease progresses that affects cerebellar function, what happens? They lose the ability control movements.
When you have movement disorders you can's slow down, instead you speed up
In patients with movement disorders, what way do they move? Side to side.
Persons with Parkinsons will lose their balance mostly when they are walking and they start to _____ in their movement. turn
If a patient does have a movement disorder and they close their eyes, what will happen. They will fall over.
What are the characteristics of meningismus? Meningismus consists of fever, clouding of consciousness, photophobia (bright light being painful to look at), nuchal rigidity, a positive Brudzinski's test, and possibly a positive Kernig's test.
Created by: 4th semester jjc
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