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NURS 507 assess neur
Assessment - neuro
| Question | Answer |
|---|---|
| where is the cardiac center, for control of heart rate | medulla ---vagus nerve has significance also |
| Where are the respiratory centers that regulate inspiration/expiration | medulla houses these centers |
| Where are the centers that regulate respiratory DRIVE (rate) | pons |
| What relays data regarding blood gases to medulla | vagus nerve |
| what area of brain controls most conscious processes | cortex |
| where is emotional expression and Broca's/expressive language located | frontal lobe |
| where is hearting/taste/smell/memory and language comprehension located (Wernicke's) | temporal lobe |
| the limbic system regulates (4) | emotions---sexual arousal---behavioral expression---recent memory |
| where does sensory input go | into the parietal lobe |
| where is RAS - reticular activating system | brainstem & cerbral cortex---hyperexcitabe neurons screens and channels incoming sensory |
| what structure controls ANS | hypothalamus, along with pituitary gland homeostasis |
| midbrain regulates (3) | visual---auditory---pupils/eye movements |
| medulla regulates (4) | heart rate---resp RATE---bp---protective reflexes (cough, sneeze, vomit etc) |
| pons regulats | respiratory FUNCTION --- facial/eye sensation and movement |
| What do DRTs assess | reflexes at various spinal cord segments |
| what are dermatones | regions of the body innervated by cutaneous branch of a single spinal nerve |
| see study guide for infants, children, pg, elderly | ***** |
| If a pt c/o these subjective data, assess neuro | h/a, recent trauma, vision changes, medications, change in mentalstatus, dizz, HTN, numbness, change in any 5 senses |
| The nursing approach for physical assessment is | inspect---palpate---cerebral function---cranial nerves---sensory function---reflexes |
| dizziness defined as | faintng sensation |
| vertigo described as | spinning sensation |
| dizziness can lead to | syncope, which is a temporary Loss of Consciousness |
| paresthesia | numbness or tingling |
| Assessment of the 5 senses is a quick way to look at | cranial never function, as intact cranial nerves are responsible for many of the senses |
| pts with dysarthria (facial/motor/speech problems) often have dysphagia . . .which could lead to | dysphia (difficulty swallowing) puts at risk for aspiration |
| What do we assess for in a neuro exam | mental status---CN fxn---sensory fxn---reflex fxn |
| how do we evaluate LOC | with a brief mental status exam, evaluation of verbal responses |
| Aside from LOC and CN testing, what other screenings for neuro | motor (strength, gait)---sensory (tactile, pain)---reflexes |
| subtle changes in LOC could be indicative of | increased ICP - be alert for these changes (forgetful, resltess, suddenly quiet) |
| layman's term for syncope | "blacking out" |
| The Glasgow coma scale has a total of 15 points to assess for LOC. How does it evaluate | best eye response---best verbal response---best motor response on a scale off 3-15---3 is non-responsive------------15 is A&Ox4 |
| mental status screening exam would include | asssessing for person (name)---time (date)---place---memory (how old are you)--remote memory (where were you born)---recent memory (what did you eat for breakfast) |
| Assessing for cerebral function with respect to thought process as well as evaluating | judgement---mathematical ability---memory---general knowledge---speech |
| three types of memory | immediate---recent---remote |
| Glascow assess what again (quick answer) | best eye-verbal-motor response |
| ways to assess for math/calculative scales | count backwards from 100---serial 7s---any simple math problem |
| how would you assess thought process? | assess appropriateness, organization and content of responses throughout assessment---involves pt considering options/choosing appropriate actions |
| how would you assess abstract reasoning? | use provers and ask for interpretation 'it's raining cats and dogs' for example----or---what do an apple, orange and pear have in common |
| can assess judgement by asking | a hypothetical situation---if you witnessed a car accident, what would you do? |
| what should I look for when assessing communication | not only the ability to speak, but the content---appropriateness---speed---quality of speech |
| How do we test for cerebellar function? | assess coordination/fine motor skills---balance |
| how do we test coordination? | rapid alternating movements - finger to nose---heel to shin |
| how do we test balance? | gait - note sequence, posture |
| The Rombereg test assesses both cerebellar and musculoskeletal functions. how do we do it | have pt stand with feet together and eyes open---then have him close the eyes. should maintain balance with minimal swaying which would be negative for Romberg |
| How do we assess sensory function? | light touch---pain---temp |
| if light touch sensation is intact distally, should we assume it is intact proximally? | nope |
| temp and pain run along same tract, so only need to test temp if | test only if pain sensation is NOT in tact |
| deep sensory sensations can be tested by | vibratory sensations (tuning fork to great toe)----kinesthetics (pt perception of position in space - move toe/finger in a direction and have pt identify it) |
| discriminatory sensations include | stereognosis---graphesthesia---Two-point discrimination---point localization---extinction |
| sterognosis | ability to recognize form of objects by touch |
| graphesthesia | recognize outlines/numbers written on skin |
| Two point discrimination | differentiating betw 2 points of simultaneous stimulation |
| point localization | ability to sense & locate area being stimulated |
| extinction | simultaneous touch both side of pts body, have pt point the where they were touched |
| how do we assess DTRs | on a scale of 0-4, 2 is normal |
| How do we test for meningeal signs (3) | nuchal rigidity---Kernig's sign---Brudzinski's sign |
| Nuchal rigidity | pronounced neck stiffness |
| Kernig's sign | supine/flex knees---apply pressure to knee while pt tries to extend leg---CONTRACTION & PAIN of hamstring and RESISTANCE in extension are POSITIVE signs of meningitis |
| Brudzinski's sign | pt supine---FLEX head to chest----if pt has HIP FLEXION---then POSITIVE for meningitis |
| What is the best test for assessing LOC | GCS = glascow Coma test is best |
| What is Babinski's test | a reflex test indicating ABN response---stroke sole of foot in arc---nml is toe flexion---abn is FANNING OF TOES W/ DORSIFLEXION of great toe |
| How do we assess for stroke | Use the NIH stroke scale ---(National Institute of Health )---assesses 12 categories with scores from ----ZERO IS NORMAL-----42 most severely impaired |
| types of categories assesson NIH stroke scale | LOC---vision---facial weakness---motor weakness---language |
Created by:
lorrelaws
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