Assessments Flashcards by Uzziel Galinea Tolosa

First Portion of Health Assessment Interview

I. Health History

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Three Segments of Health History

Current Health History
Past Health History
Family Health History

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An Assessment of the Neurologic System involving Vital Signs

II. Physical Assessment

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An assessment involving:
• Mental status assessment
• Cranial nerves
• Sensory function
• Motor function
• Cerebral function
• Reflexes

III. Neuro-Physical Examination

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What are the three key ideas we assess within the Mental Status Assessment?

Assess Appearance (general presentation/dress, hygiene, grooming, GAIT, and POSTURE)
Assess Behavior (Actions and Affect, Content and Quality of Speech, and LEVEL OF CONSCIOUSNESS (LOC) - Includes Glasgow Coma Scale)
Assess Cognitive Function (Note Orientation to Time, Place, and Person; Attention Span; Recent and Remote Memory)

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Checking the patency of both nostrils, then instruct the patient to close his eyes.

Cranial Nerve Assessment
> CN I Olfactory

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It is an inability to smell

ANOSMIA

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It occurs when the capillaries under the skin get damaged or rupture, causing bleeding / leakage of blood;

CAUSES:
Increased pressure,
Trauma,
Certain medical conditions (i.e. thrombocytopenia, vasculities)

This condition may significantly affect the HYPOTHALAMUS or BRAIN STEM

Petechial Hemorrhage in relation to the Hypothalamus/Brain Stem

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Damage to the __ and __ can alter the body temperature

Hypothalamus and Brain Stem

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Some genetic diseases are degenerative, others cause muscle weakness;

e.g.
Seizures are more common in patients whose family history shows (1.) __________, and 50% with (2.) ________

Idiopathic Epilepsy
Migraine

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Because the ANS controls heart rate and rhythm, pressure in the brain stem and cranial nerves allows the heart rate by stimulating the _______

Vagus Nerve;

Autonomic Regulation - helps manage HR, breathing, and digestive processes; slows HR if needed, promotes digestion if needed

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__cardia occurs in a patient in the LATER STAGE of Increasing ICP and with Cervical Spinal Cord Injury

Bradycardia

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__cardia occurs in a patient with ACUTELY INCREASING ICP or a Brain Injury;

This signals decompensation, a condition in which the body has exhausted compensatory measures for managing ICP, which rapidly leads to death

Tachycardia

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The Pressure Receptor in the _____ _____ continuously monitors Blood Pressure

Medulla Oblongata

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____ ____ ____ ____ may interrupt SNS Pathways, causing Peripheral Vasodilation and Hypotension

Cervical Spinal Cord Injury

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Respiratory control in the ____ and ____ controls the Rate, Depth, and Pattern of Respiration

Medulla and Pons

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Neurological Problems involving the ___ and ___ commonly alter RESPIRATION

Brain Stem and Cerebral Hemispheres

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What are the Six Aspects we Assess within the Neuro-Physical Examination?

Mental Status Assessment
Cranial Nerves
Sensory Function
Motor Function
Cerebral Function
Reflexes

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This condition refers to INATTENTION to one side of the body

Unilateral Neglect;
May occur with some strokes

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Temporary disruption of blood flow to the brain

Transient Ischemic Attack;
“Mini-Stroke”

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The face appears “Mask-Like” in clients with:

Parkinson’s Disease

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Stroke may come with what significant changes in the client’s behavior?

Emotional Swings and Personality Changes

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These are seen with damage to the left cerebral cortex;

is a disorder that affects how you communicate. It can impact your speech, as well as the way you write and understand both spoken and written language.

Aphasia

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Aphasia is common with what two neurological disorders?

TIAs & Stroke

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It is a condition seen with paralysis of the vocal cords (CN X); It is common in what disorder?

Dysphonia; Common in Stroke

In relation to Parkinson’s Disease, this condition affects facial expression, making it difficult to express emotions or use the facial muscles as normal. Basic facial movements, such as raising an eyebrow or smiling, may be difficult

Hypomimia

It is a condition seen with lesions of the: 1. upper and lower motor neurons; 2. the cerebellum; 3. the extrapyramidal tract is where you have difficulty speaking because the muscles you use for speech are weak. It can be caused by conditions that damage your brain or nerves and some medicines.

Dysarthria

An altered Level of Consciousness (LOC) may indicate damage/injury to the: ___ & ___

Brainstem and Cerebral Cortex

What are the three Responses being assessed in the Glasgow Coma Scale?

1. Eye opening response 2. Verbal response 3. Motor response

In GCS, a score of 8 and below indicates that the patient is ____

In a Comatose State / Severe Brain Injury

Altered LOC is seen in damage to the ___ & ___

Brainstem and Cerebral Cortex

Damage to the Brainstem or Cerebral Cortex may involve:

* Brain Trauma * Neurological Infections * TIAs * Stroke * Brain Tumor

A score of 9-12 in the GCS means:

Moderate Brain Injury

A score of 13 and above means

Mild Brain Injury

This assessment under MSA involves: * General presentation * Dress/Clothing * Hygiene * Grooming * **Gait and Posture**

Assessing *Appearance*

This assessment under MSA involves: * Actions and Affect * Content and Quality of Speech * Level of Consciousness

Assessing *Behavior*

This assessment under MSA involves: * Orientation to time, place, and person * Attention span * Recent and remote memory

Assessing *Cognitive Function*

Under assessing the client’s cognitive function (MSA3), we ask the client to what? 1. 2. 3.

1. Repeat five to seven numbers 2. Recall three items after 5 mins. 3. Recall their address, breakfast, or birthday

Two aspects in assessing THOUGHT PROCESSES (done by noting responses to questions)

Content & Perceptions

Disorientation to time and place may indicate what?

A Stroke of the Right Cerebral Hemisphere

Memory/Perceptual Deficits are often seen in clients with what neurological disorder?

Strokes

Impaired Cognition are commonly associated with what neurological disorders?

Strokes Cerebral Trauma Brain Tumors

What assessment tool do we use for assessing Cranial Nerve II (Optic)

Snellen Chart

To test the patient’s visual acuity QUICKLY & INFORMALLY, have the patient read a ____, starting with a large headlines, and moving to small prints

Newspaper

To test VISUAL FIELDS, use the _____ _____; to do this, stand 2 inches in front of the patient, and have them cover one eye. Then bring your moving fingers into the patient’s visual field from the periphery. Ask them when they see the object

Confrontation Technique

How do we assess EXTRA-OCULAR MOVEMENT of the client?

Asking the client to FOLLOW your FINGER as you WRITE an “H” on AIR

How do we assess PERRLA

By COVERING ONE EYE at a time and SHINING a BRIGHT LIGHT directly into the uncovered eye using a PENLIGHT

A condition wherein there is an unequal pupil size. The pupil is the black part in the center of the eye. It gets larger in dim light and smaller in bright light.

Anisocoria

Blindness in one eye can be associated with what neurological disorders?

Strokes or TIA

Impaired vision or blindness in one side of both eyes

**Homonymous Hemianopia** *Hemianopia is the loss of half of a person's field of vision. This can occur due to a variety of factors, but it most commonly results from a stroke.*

Assessment involving evaluation of the patient’s Extra-ocular Eye Movement

CN III, IV, and VI (Oculomotor, Trochlear, and Abducens)

Involuntary eye movement

Nystagmus

Inability to move eye in a direction

Ophthalmoplegia

Double vision

Diplopia

Drooping eyelids

Ptosis / Horner Syndrome

This disorder regarding drooping eyelids is commonly seen in:

Stroke Myasthenia Gravis Palsy of CN III

Assessing the patient’s ability to feel light, dull, and sharp sensations on the FACE

CN V (Trigeminal)

Checks whether face sensation is the same on both sides of the face (with pt’s eyes closed)

CN V (Trigeminal)

This assessment involves assessing the Corneal Reflex by touching the corneal surface with a wisp of cotton

CN V (Trigeminal)

This abnormal finding can be seen in impaired blood flow to the CAROTID ARTERY (this is regarding CN V)

Changes in Facial Sensation

Decreased sensations to the face and cornea on the same side if the body and Numbness of lips and mouth can be seen in what neuro disorder

Stroke

What can cause a loss of sensation/contraction of the masseter and temporal muscles?

LESIONS in CN V

Severe Facial Pain

Tic Douloureux

Assess the ability to taste sweet, sour, and salty on the Anterior Two-Thirds of the Tongue by asking the client to stick out the tongue, and applying sweet, salty, and sour substance

CN VII (Facial)

Assess ability to frown, show teeth, raise eyebrows, smile, and close eyes tightly

CN VII (Facial)

Loss of ability to taste can indicate or associated with what abnormality in the brain and/or nerves

Brain tumors / Nerve Impairment

This condition results in an inability to close eyes; flat, nasolabial fold; paralysis of the lower face; inability to wrinkle the forehead

Paralysis of lower motor neuron r/t injury to CN VII

Pain, Paralysis, and Sagging of Facial Muscles are seen in the AFFECTED SIDE of what Neurological Disorder?

Bell’s Palsy

Assess the ability to hear the ticking of a watch and whispered and spoken words

CN VIII (Acoustic)

A test with a tuning fork that is struck and placed in the middle of the patient’s forehead. The patient compares the loudness on BOTH SIDES

Weber Test; CT Scan for Accurate Confirmation If there is UNEVEN HEARING, there is Conductive Hearing Loss

A tuning fork is heals against the Mastoid Process until it can no longer be heard. It is then brought to the ear to evaluate patient response

Rinne Test

Difficulty swallowing

Dysphagia

Occurs with lesions in CN IX & X

Unilateral loss of gag reflex and Dysphagia

Assessing gag reflex, observing symmetrical rise of the soft palate and uvula as the patient says “ah”, assess ability to taste, salty, sweet, and sour on the *posterior third of the tongue*

CB IX & X

Assess the client’s ability to shrug the shoulder and turn head against resistance

CN XI (Accessory/Spinal Accessory)

Muscle weakness is noted with what Neuron disease

Lower Motor Neuron Disease

Regarding abnormal findings of the CN XI (Accessory) assessment, this is seen with Strokes

Contralateral Hemiparesis

weakness on the opposite side of the body, occurs due to damage in the brain or spinal cord, specifically affecting the motor pathways that control movement

Contralateral Hemiparesis

Assess the client’s ability to stick out tongue, and move the tongue from side to side against the resistance of a tongue depressor

CN XII (Hypoglossal)

Twitches of the Tongue

Atrophy and Fasciculations of CN XII

Tongue deviation can be associated with what neuro disorder?

Stroke; LOWER or UPPER MOTOR NEURON **LESION**

Assessing (1) ability to perceive various sensations, (2) sense of position, and (3) ability to discriminate fine touch

Sensory Function Assessment

Term referring to awareness of the position and movement of the parts of the body by means of sensory organs (proprioceptors) in the muscles and joints.

Kinesthesia

Decreased sensation to pain may indicate injury to what sensory tract / major sensory pathway

Spinothalamic tract injury

Decreased vibratory sensation may indicate injury to what tract (also a major sensory pathway)

Posterior Column Pathway/Tract

Transient numbness of the face, arm, or hand

TIA

Object in hand such as coin or key

Tests **Stereognosis**

Number written on hand

Tests *Graphesthesia**

Two points of simultaneous pinpricks on the hand

Tests **Two-point Discrimination**

Where they are being touched assessment

Tests **Localization**

How many sensations are felt when touched simultaneously on both sides of the body

Tests **Extinction**

Assessment involving (1) Bilateral symmetry and size of muscles, (2) Muscle tone, (3) and Bilateral muscle strength and movement

Motor Function Assessment

Assessing the Gait (assess balance, and the smoothness of movement) and Coordination

Cerebellar Function Test

A test done in Cerebellar Function Test

ROMBERG’s TEST

Lack of coordination and clumsiness of movements with staggering, wide, based, and unbalanced gait

Ataxia

If positive for ROMBERG’s TEST, can be associated with what disorder

Cerebellar Ataxia

Assessing normal response of Flexion at the Elbow and Contraction of the Biceps

Biceps Reflex (DTR1)

Assessing if the Tendon contracts and Elbow Extends

Triceps Reflex (DTR2)

Assessing the posterior arm about 2 inches above the wrist on the thumb side

Brachioradialis (DTR3)

Assessing if the forearm could rotate laterally and the palm turning upward

Brachioradialis (DTR3)

Assessing if the normal response of contraction of the quadriceps muscle with an extension of the knees

Patellar Tendon Reflex / Knee Jerk Reflex

Assessing if there is slight jerking of the foot

Achilles Tendon Reflex

Assessing DTRs and the *Superficial Abdominal and Cremasteric Reflexes*

Reflexes Assessmeny

The upper arms are closed to the sides; the elbows, wrists, and fingers are flexed

Decorticate Positioning/Rigidity

The neck is extended, with the jaw clenched; the arms are probated, extended, and close to the sides

Decerebrate Position / Rigidity

ICP is measured in what Ventricle

Lateral Ventricles

Normal range of ICP

0-10 mmHg

Contents within Cranial Vault

Blood Brain Tissue Cerebrospinal Fluid