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NURS 507 assess neur

Assessment - neuro

QuestionAnswer
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