NM: Exam Flashcards
Examine: Level of Consciousness
- tests
- levels of consciousness
- Orientation x 3 (person, place, time)
- Response to stimuli: purposeful, non-purposeful or no response; verbal, tactile, simple commands; painful stimuli: pinprick or pinch
Determining LoC:
- –Alertness: Responds appropriately, can OE and look at examiner, respond fully and appropriately to stimuli
- –Lethargy: Patient’s appearance: drowsy, can OE, look at examiner, respond to questions but falls “asleep” easily
- –Obtundation: can OE, look at examiner but responds “slowly” and is “confused”; decreased alertness and interest in environment
- –Stupor: can be “aroused” from sleep ONLY with painful stimuli, verbal response slow or absent, return to “unresponsive state” when stimuli removed; min awareness of self and environment
- –Coma: a state of “unconsciousness”, no arousal at all even with external stimuli, eyes remain closed
- –Unresponsive vigilance (vegetative) state: characterized by sleep/wake cycles, normalization of vegetative functions (RR, HR, BP and digestion) and lack of cognitive responsiveness (aroused but unaware)
- –Persistent vegetative state: state > 1 yr for (TBI) and > 3 months for (anoxic brain injury)
- –Minimal conscious state (MCS): characterized by “severely altered consciousness” with minimal but definite evidence of self or environmental awareness
-Glasgow Coma Scale
Glasgow Coma Scale
—Looks at 3 elements of response: EO, motor and verbal response
—Scoring 3-15:
3-8 = severe brain injury
9-12 = moderate
13-15 = min
Examine: Cognitive Fxn (Memory)
- –Immediate recall: name 3 items previously presented after a brief interval
- –Recent memory (short term): recall of recent events
- –Remote memory (long term): recall past events
Examine: Cognitive Fxn (Attention)
- –Length of attention span: digit span retention test (ex: ability to recall 7 numbers in order of which it was presented)
- –Sustained attention: ability to tend to task without re-direction
- –Divided attention: ability to shift attention from one task to another; assess ability of “dual-tasking” and perserveration (mental inertia): getting stuck on a task
- –Focused attention: ability to stay on task in presence of distractors; assess impact of environment vs internal distractors
- –Ability to follow commands: 1 or 2 step commands or multi-level commands
Examine: Cognitive Fxn (Emotional Response/Behavior)
- –Safety, judgement: impulsivity and lack of inhibition
- –Affect, mood: irritability, agitation, depression and withdrawal
Higher-level Cognitive abilities:
- –Judgement, problem solving, abstract reasoning
- –Fund of general knowledge: “Ability to learn new information”, generalize learning to new situations, Calculation: “serial 7 test” (count backwards from 100 by 7s), Sequencing: ability to order components of cognitive or functional tasks; assess if cueing is necessary, frequency of cues
Mini-Mental State Examination (MMSE)
—Brief screening test for “cognitive dysfunction”
—Includes items for: orientation, registration, attention and calculation, recall and language
—Max score 30
21-24 (mild cognitive impairment)
16-20 (mod)
<15 (severe)
Rancho Los Amigos Level of Cognitive Function (LOCF)
—Assess cognitive recovery from “TBI”
—Eight levels:
Level 1: No response
Level 2-3: decreased response
Level 4-6: confused
Level 7-8: appropriate (automatic, purposeful)
—Delineates emerging behaviors; patients may plateau at any level
Examine:
Speech
(Determine type of Aphasia )
Non-fluent/Expressive/Broca’s Aphasia =
- –Lesion: 3rd frontal convolution of the Left hemisphere
- –A central language disorder in which speech is typically awkward, restricted, interrupted and produced with effort
Fluent/Wernicke’s/Receptive Aphasia =
- –A central language disorder in which spontaneous speech is “preserved” and flows smoothly, while “auditory comprehension” is impaired
- –Lesion: posterior first temporal gyrus of the L hemisphere
Verbal Apraxia / Dysarthria
—impairment of speech production resulting from damage to central or peripheral NS; causes weakness, paralysis or incoordination of motor-speech system (respiration, articulation, phonation, and movements of jaw and tongue)
Global Aphasia
- –Severe Aphasia
- –Examine for marked impairments in comprehension and production of language
Examine: Speech
Non-verbal communication
- –Examine ability to read and write
- –Use of gestures, symbols and pictographs
Examine: Vital Signs
- –HR increases in DIRECT proportion to intensity of exercise (SBP: increases, DBP: remains the same or decreases slightly)
- –With increasing intra-cranial pressure, examine for late HR and BP changes
- –Temperature : High temperature may indicate infection, damage to the hypothalamus or brainstem
Examine: Vital Signs
Types of Respiration
Cheyne-stokes Respiration
—a period of apnea lasting 10-60 seconds followed by gradually increasing depth and frequency of respirations; accompanies depression of “frontal lobe” and “diencephalic” dysfunction
Hyperventilation: increased rate and depth of respiration; accompanies dysfunction of lower mid-brain and pons
Apneustic breathing: Abnormal respiration marked by prolonged inspiration; accompanies damage to the UPPER pons
Examine for CNS Infection or Meningeal Irritation
Signs are GLOBAL not focal
—Kernig’s Sign: patient is positioned in supine, flex hip/knee fully to chest and then extend knee.
(+): causes pain and increased resistance to “extending knee” d/t spasm of hamstring; when bilateral suggests “meningeal irritation”
—Brudzinki’s sign: patient positioned in supine, flex neck to chest
(Pos): causes flexion of hips and knees (drawing up), suggest meningeal irritation
—Slowed mentation function: persistent H/A, worse in head-down position, may progress to delirium, lethargy and coma
—Generalized weakness
Examine: Reflexes (DTRs)
DTR: normally occurring reflexes in response to stretch of muscle Common reflexes: jaw, trigeminal (CNV), biceps (C5-6), triceps (C7-8), brachioradialis (C5-6), HS (L5-S3), quads L2-4), Achilles (S1-2) Scoring: 0 : absent 1+ : decreased response 2+ : normal response 3+ : exaggerated 4+ : hyperactive
Examine: Reflexes (Superficial Cutaneous)
normally occurring reflexes in response to “noxious stimulus” (light scratch) applied to skin
Plantar Reflex (S1-2, tibial n) - stroking of lateral sole of foot from calcaneus to base of 5th met and medially acroos met heads produces toe PF Positive Babinsky Response: great toe DF and ABD of lesser toes; seen in patinets with corticospinal lesions
Abdominal Reflexes: lateral to medial scratching of skin (towards umbilicus) in each of four quadrants produces deviation of the umbilicus toward the stimulus ; loss = sign of corticospinal reflexes
Cremasteric Reflex (L1-2) : stroking of skin of the proximal and medial thigh produces elevation of the testicle; absent in SCI and coriticospinal lesions
Examine: Reflexes (primitive/spinal reflexes)
*present developmentally in normal infants and in some pts with brain injury
Flexor Withdrawal : noxious pinprick to sole of foot
normal response: toe EXT, foot DF, LE FLX
Crossed Extension Reflex: noxious stim to sole of foot
normal response: LE FLX and contralat LE EXT/ADD
Traction: stretch stim from grasping the forearm and pulling
normal response: UE FLX
Grasp: maintained pressure to palm of hand (PALMAR GRASP) or ball of foot (PLANTAR GRASP)
normal response: maintained FLX of fingers or toes
Examine: Reflexes (tonic/brainstem reflexes)
*present developmentally in normal infants and in some pts with brain injury
ATNR (asymmetrical tonic neck reflex): head ROT
normal response: ipsil UE EXT, contral UE FLX
STNR (symmetrical tonic neck reflex: - head FLX normal response: UE FLX and LE EXT - head EXT normal response: UE EXT and LE FLX
Positive supporting: contact to ball of foot in standing
normal response: rigid EXT of LEs
Associated reactions: strong voluntary mvmt in one body segment
normal response: involuntary mvmt in another resting extremity
Involuntary movements seen in extrapyramidal disorders and basal ganglia dysfxn
TICS: spasmodic contractions of specific mm, commonly involving face, head, neck, or shoulder mm
CHOREA: relatively quick twitches or dancing mvmts
ATHETOSIS: slow, irregular, twisting, sinuous mvmt
TREMOR: continuous quivering mvmts; rhythmic, oscillatory mvmt observed at rest (resting trmor)
MYOCLONUS: single, quick jerk
Involuntary mvmts seen in Cb disorders
INTENTION TREMOR occuring when voluntary mvmt is attempted
Involuntary mvmts seen in cortical disorders
EPILEPTIC SEIZURES
TONIC/CLONIC CONVULSIVE MVMTS
Examine : Balance
Visual system: visual acuity, depth perception, visual field defects
Somatosensory: proprioception, cutaneous sensation (touch, pressure), LE and trunk (esp feet/ankles)
Vestibular: observe balance with changes in head position
Tests:
- sensory organization test
- CTSIB
Performance-Oriented Mobility Assessmetn (POMA, Tinetti)
Examines balance (9 Items including sit<>stand, standing, standing with feet together, turning 360 degree, sternal nudge, stand on one leg, tandem stand, reaching up, bending over, stand-to-sit , timed rising) Examines Gait: (8 items including gait initiation, path, turning timed walk, step over obstacles)
Max score 28 (higher=better)
<19 high risk for falls
19-24 mod risk for falls
Berg Balance Scale
Examines functional balance (14 items including sitting unsupported, sit<>stand, stand<>sit, transfers, in standing EO to EC, feet together, forward reach, pick object off the floor, head turns, turning 360 degrees, stepping up, tandem stand, stand on one leg
Uses “Ordinal Scale”
Max score = 56 (higher=better)
<45 : high risk for falls
*with 46-54 a 1-point drop is associated with a 6-8% increase in fall risk
