Help
Options
Didn't know it?
click below
click below
Knew it?
click below
click below
Don't Know
Remaining cards (0)
Know
retry
shuffle
restart
0:00
Embed Code - If you would like this activity on your web page, copy the script below and paste it into your web page.
Normal Size Small Size show me how
Normal Size Small Size show me how
FON exam 3
neurologic assessment and nursing process
| Question | Answer |
|---|---|
| CNS assessment | brain and spinal cord |
| peripheral nervous system assessment | 12 pairs of CN, spinal and peripheral nerves |
| neuro assessment parameters | mental status, cranial nerves, motor system, sensory system, reflexes |
| mental status assessment | LOC, appearance/behavior, speech/language/communication, thought process/judgement |
| what to assess in LOC | awake and alert? oriented x3? - person, place, time |
| when assessing orientation... | person place time - be aware that even you don't always know the date event/situation - if using A&O x3 (do yk why you're here) |
| person | the pts own name and name of relatives and professional personnel - "can you tell me your name" |
| place | the pts residence, city and state "what is your address" |
| time | time of day, day of the week, month, season, date and year, duration of LOS - "can you tell me what time it is now, and what day it is" |
| situation | what just happened/is happening (frequently used after an accident or anesthesia - "can you tell me what just happened" |
| lethargic | sleepy/drowsy asleep more than awake easily arousable with verbal and tactile stimuli - shake, talk to will respond to questions - may be appropriate or not appropriate |
| obtunded | pt will: open their eyes to verbal/tactile stimuli look at you respond - slowly, confused become unresponsive if not stimulated |
| stuporous | not good! no spontaneous movement if not aroused - must be shaken or shouted at inappropriate verbal response purposeful response to pain - pull away or hit |
| a stuporous pt is | nearly unconscious with apparent mental inactivity and reduced ability to respond to stimulation |
| comatose | patient will be unconscious and unresponsive cannot be aroused even with pain |
| when should you focus on your assessment on mental status | pt is confused (if new, do neuro assess) family/pt concerns - "just not acting herself" acute behavioral changes long or short term memory loss aphasia - |
| mental status - beyond LOC and assess | general appearance and behavior speech and language mood cognitive function |
| mental status - assessing appearance and behavior | pt has appropriate concerns regarding care body mvmts - control, symmetry, appropriate, full/limited ROM posture - upright, slumping gait - smooth, unassisted, assisted (how they walk) calm, restless, anxious, combative eye contact |
| mental status - assessing appearance and behavior | gathering info to identify a problem - not diagnosing grooming/dressing - clean, age appropriate? weather appropriate? both sides equal? |
| abnormal findings in mental status - assessing appearance and behavior may be due to | depression, schizophrenia, dementia, OCD, CVA, visual disturbances, MS |
| mental status - assessing appearance and behavior: facial espression | appropriate, symmetrical: smile = unequal if pt is oriented, you can say "hey i noticed a droop, normal?" |
| mental status - speech and language (communication) | spontaneous/coherent speech? effortless flow? normal intonations, rate, rhythm? content makes sense? able to comprehend and reply appropriately? |
| aphasia | loss of ability to understand or express speech, caused by brain damage impairment of language function pt cannot produce language (expressive), understand language (receptive), or both (global) |
| aphasia is | a language disorder that affects a persons ability to communicate |
| expressive aphasia | brain knew what to say but mouth could not say it |
| receptive aphasia | not understanding what they're saying |
| causes of aphasia | CVA, TBI, brain tumor/surgery, infection (temporary), migraine (temporary) |
| mental status assessment: appearance, behavior, speech | flat affect - depends on culture manic depressive - describe instead of diagnose anger/hostility - may escalate quickly, have an escape!! |
| mini mental status exam (MMSE) - standardized tool | brief questionnaire must be fluent in english and have an 8th grade education max of 30 points half = cognitively impairment |
| 5 components of the MMSE | appearance and behavior speech and language mood thoughts and perceptions cognitive function |
| mental status assessment: cognition | newer, high degree of validity mini cog test screens for cognitive impairment in older individuals |
| mini cog tes | high sensitivity and specificity for detecting cognitive impairment |
| screens for cognitive impairment in older individuals | 3 word recall test for memory clock drawing test |
| cranial nerves | I - XII 12 pairs grouped by how they are tested/assessed always assess symmetry! |
| function of cranial nerves | the functions of the CNs are sensory, motor or both |
| sensory CNs | help a person to see, smell, and hear |
| motor CNs | help control muscle movements in the head and neck |
| I - olfactory | smell |
| II - optic | vision |
| III - oculomotor | eye movement (most muscles), pupil constriction, eyelid elevation |
| IV - trochlear | down and inward movement of eye |
| V - trigeminal | facial sensation, muscles of chewing |
| VI - abducens | lateral movement of eye |
| VII - facial | facial expression/movement, taste on anterior tongue, saliva and tear secretion |
| VIII - acoustic | hearing and balance |
| IX - glossopharyngeal | taste on posterior tongue, swallowing, gag reflex, salivation |
| X - vagus | autonomic control of heart, lungs, GI tract, swallowing, speech, gag reflex |
| XI - spinal accessory | shoulder shrug and neck turn |
| XII - hypoglossal | tongue symmetry and position |
| assessment of the CNs | involves focused, relevant assessments requires multi-modal approach essential to establish a baseline on which to compare future assessments |
| brief CN assessments | visual acuity - snellen chart, confrontation: CN II eye movements - 6 card fields, PERRLA: CN III, IV, VI sensation: CN V tongue movement: CN XII facial movement: CN VII shoulder shrug, neck movement: CN XI |
| 20/20 vision | normal vision, can read from 20 ft away |
| CN I | olfactory tests for smell don't typically test bc can be from normal head cold |
| CN II | optic assessing confrontation |
| 6 cardinal fields of gaze | assesses extraocular muscle function and the CNs that control them (CN III, IV, VI) assess for smooth, coordinated eye movements in all 6 directions checking for nystagmus, no strabismus, no diplopia |
| nystagmus | involuntary jerky eye movements |
| strabismus | misalignment/crossing of eyes might only appear when testing eye gaze |
| diplopia | double version reported by the patient |
| pupillary light reaction | PERRLA |
| checking pupils: ISSUES | pinpoint eyes: drugs! huge pupils |
| when checking pupils, assess accommodation | which is the eyes ability to adapt for near vision |
| ptosis is a problem with | the levator muscle causes droopy eyelid |
| ptosis means problem with what CN | CN III |
| facial sensation CN V | trigeminal motor function and sensory function |
| motor function | palpate temporal and masseter muscles as patient clenches teeth |
| sensory function | test light sensation with cotton ball over |
| facial movement CN VII | ask pt to raise eyebrows, close eyes tightly, smile, puff out cheeks |
| why dont we typically test sense of taste | because so many things can affect this, increase of age = taste buds die off |
| CN XI | spinal accessory motor function - rotate head against resistance, shrug shoulder against resistance |
| advanced CN testing | VIII - acoustic and vestibulocochlear IX - glossopharyngeal X - vagus |
| VIII - acoustic and vestibulocochlear | whisper test (hearing) rinne & weber (use tuning fork to differentiate type of hearing loss) |
| IX - glossopharyngeal X - vagus | taste, swallow, gag, voice - hoarse? dysphagia? |
| quick CN assessment is what we | do at bedside |
| quick CN assessment entails | PERRLA, facial expression, speech, have patient smile/frown, stick out your tongue, assess hand grasps/pedal pushes |
| assessing the motor system for | body position involuntary movements tone, strength, equality coordination - age dependent to an extent |
| body position | relaxed, normal position/shape ask if they have an involuntary movements or tremors |
| involuntary movements | tremors tics - brief repetitive movements, winks, shrugging fasciculation - involuntary contraction/twitching, under skin dystonia - grotesque twisted postures |
| also assess motor system for | muscle atropy/wasting hypotonic/flaccid muscles increased resistance - spasticity |
| paresis | weakness |
| plegia | absence of strength or paralysis |
| hemi | one side of the body, arm and leg |
| para | trunk and lower limbs, wheel chair |
| quadri | all 4 limbs and torso |
| easy assessment for muscle movement | hand grasp and pedal pushes |
| what can muscle movement abnormalities be caused by | stroke, SCI, neurological diseases, nerve damage |
| motor system assessment of neuro status: coordination | muscle strength cerebellar system for rhythmic movement and steady posture vestibular system for balance and coordinating eye, head, and body movements sensory system for position sense |
| how to assess coordination | gait walk heel to toe walk on heals, walk on toes hop in place with shallow knee bed step on stool of rise from seat without using arms |
| ataxia | gross lack of coordination of muscle movements dysfunction of parts of the nervous system that coordinate movement |
| people with ataxia walk like | they're drunk |
| ataxia is caused by | hereditary, parkinsons and huntingtons brain damage, alcohol and drugs, tumors |
| stance and balance | romberg's test pronator drift test |
| rombergs test | eyes open = steady stance eyes closed = patient will sway |
| pronator drift test | closed eyes, palms up = arms will pronate as they drift down |
| what is sensory | pain, position and vibration, light touch, discrimination compare for symmetry! |
| pain - sensory system assessment | sensation! is it sharp or dull? use a broken cotton swab or paper clip avoid the word pain |
| position - sensory system assessment | have pt close their eyes, ask them to tell you if you are moving their toe up, down, left, right |
| vibration - sensory system assessment | use tuning fork, start distal to save time |
| light touch | use cotton ball, touch cotton ball to pts skin, while their eyes are closed, have them tell when they feel the cotton ball touching their skin |
| discrimination | stereognosis graphesthesia |
| stereognosis | recognizing an object using the sense of touch |
| graphesthesia | recognize writing on the skin using the sense of touch |
| plantar reflex | stroke up the lateral side of the sole and across the ball of the foot to just below the great toe plantar flexion of the toes = normal response |
| plantar reflex is a | negative babinski sign |
| positive babinksi | abduction of the toes with dorsiflexion of the great toe is something you do not want to see in an adult |
| clonus | series of involuntary muscle contractions due to sudden stretching of the muscle |
| clonus causes | large motions that are usually initiated by a reflex |
| neuro assessment tools - glascow coma score | GCS 3 areas of assessment - eyes open, motor response, verbal scale desired/perfect score is 15 |
| GCS: eyes open | spontaneous = 4 to verbal command = 3 to pain = 2 no response = 1 |
| GCS: motor response | obeys command for movement = 6 purposeful movement to painful stimuli = 5 withdraws in response to pain = 4 flexion in response to pain = 3 extension response in response to pain = 3 no response = 1 |
| GCS: verbal scale | oriented = 5 disoriented/confused = 4 inappropriate words = 3 incomprehensible sounds = 2 no response = 1 |
| stroke warning signs | sudden numbness or weakness of the face, arm, or leg; especially on one side of the body sudden confusion, trouble speaking/understanding sudden trouble seeing in one or both eyes sudden trouble walking/dizziness, loss of balance/coordination |
| FAST warning signs | F = face drooping A = arm weakness S = speech difficulty T = time to call 911 |
Created by:
leh195