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Health Assessment > Ch 22: Neurological and mental status > Flashcards

Ch 22: Neurological and mental status Flashcards

1
Q

What parts does the nervous system
include

What part did the peripheral nervous system include

A

Nervous system parts:

  • CNS
  • Brain
  • spinal cord

Peripheral nervous system parts:

  • cranial
  • spinal
  • peripheral + associated nerves
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2
Q

How is the nervous system classified

Give the parts of classification

A

Nervous system classified by function

Somatic (voluntary)

  • Control skeletal muscle
  • Motor

Autonomic (involuntary)

  • Controls everything else
  • senses
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3
Q

What bigger system or the sympathetic and parasympathetic nervous system is a part of

Differentiate sympathetic versus parasympathetic nervous system

A

Sympathetic and parasympathetic nervous system‘s a part of autonomic (involuntary) nervous system

Sympathetic: fight V flight

Parasympathetic: rest and digest

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4
Q

What will a patient exhibit if they have a CVA on the left side

What will the patient exhibit if they have a CVA on the right side

A

L CVA: motor and sensory deficit on R

R CVA: motor and sensory deficit on L

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5
Q

What is the brain considered

Give the parts of the neuron including characteristics of axon and How neurons communicate

A

 Brain: network of interconnecting neurons that control/integrate body

Neuron:
-cell body (control) 
-dendrites (receiving fibers) 
-axon (connecting fibers)
• White because of my sheet that spreads impulse

Neurons communicate at synapse

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6
Q

What is the function of the cerebral cortex where is it located within

Give the divisions of the cerebrum and would each known for

A

Cerebral cortex: contributes to motor and sensory function, language

Cerebrum divided into two hemispheres
-L: analytical
(math logic lang)

-R: creative
(art music emotion)

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7
Q

Where is the precentral gyrus and what is it known for

what does it control
How does this relate to the CVA

A

Precentral gyrus located in the frontal lobe is the primary motor area

Precentral gyrus controls motor to opposite side of body

Pre-central gyrus associated with CVA presentation

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8
Q

Give the function of the frontal lobe

What is the function of the Broca area

A

Frontal:

  • cogn
  • mem
  • personality/emotion

Broca area: expresses communication and regulates verbal/writing ability

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9
Q

Give the function of the perinatal lobe

Where is the warnicke area and what is it known for

A

Parietal:

  • interprets touch
  • pressure/pain

Warnicke area: LOC left hemisphere
-known for the perception of communication (spoken and written)


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10
Q

Give the function of the occipital lobe

give the function of the temporal lobe

A

Occipital: primary visual area

Temporel: hearing, speech, behavior

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11
Q

Give the 4 parts of the brain stem their function

A

Brain stem:

  1. Medulla (autonomic)
    - resp,cardio, vasomotor
    - cells bodies of CN3 – 12
  2. Midbrain: relays info from brain using ascending (sensory) and descending (motor)
  3. Ponds: controls inspiration/expiration + resp rate
  4. Reticular formation: wakefulness and attention
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12
Q

What is a brainstem known for as far as stimuli ans where the stimuli goes + Direction of stimuli

A

•Afferent (sensory): ascending
-travels sensory information to cerebral cortex

•Efferent (Motor): descending
-from cortex to brainstem and spinal cord 

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13
Q

What function of the brain controls involuntary function like sneezing and swallowing

A

The medulla of the brainstem controls involuntary function like sneezing and swallowing

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14
Q

Give the section of the brain stem and the cranial nerves that correspond to

(Think of a picture green, purple, blue, they’re already in order 2,4,4)

A

Midbrain: 3&4

Ponds: 5,6,7,8

Medulla: 9,10,11,12

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15
Q

What is the function of the cerebellum

how do you test the cerebellum

and what may affect the cerebellum

A

Cerebellum functions for coordination and equilibrium

Cerebellum tested with Romberg

Alcohol can affect the balance and coordination in the cerebellum

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16
Q

What are brain ventricles

How far does a spinal cord extend

A

Brain ventricles are fluid filled cavities that connect to spinal cord

Spinal cord extends from base of skull to coccyx


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17
Q

What is the function of CSF

A
  • carries nutrients
  • cushions
  • allows for fluid to shift between brain and spinal cord to prevent increased intercranial pressure (ICP)
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18
Q

In the peripheral nervous system:

How many cranial nerves do we have

How many spinal nerves do we have

if a spinal nerve becomes injured where does injury take place what kind of injury

A

 12 pairs of CN

31 pairs of spinal nerves
-depending on the level of injury to the spinal cord injury can affect at or below side of trauma both century and motor

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19
Q

What are dermatomes

A

Dermatomes are afferent sensory fibers

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20
Q

 Give the major divisions of the autonomic nervous system,
The neurotransmitter associated and actions
(2 previously stated, think back)

A

Autonomic nervous system (involuntary)

-sympathetic: fight the flight
• Epinephren ⬆️ vitals (BP/ HR)

-parasympathetic: rest and digest
• acetylcholine⬇️

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21
Q

What does the autonomic nervous system make changes based on

What innervates bilat regions of skin

A

Autonomic nervous system makes changes based on received info

Bilat regions of skin intervated by spinal nerves

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22
Q

Give the 4 reflex arc components

-With their real world comparison

A
  1. Receptor sensing organ
    - Patellar tendon
  2. Afferent sensory neuron
    - root of ganglion

Synape in spinal cord

  1. Efferent motor neuron
  2. Effector motor organ
    - quadriceps contracts and jerks
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23
Q

How would you define reflexes

A

Reflexes are involuntary response to stimuli

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24
Q

Lifespan considerations for older adults related to CNS age related changes

Brain vol
Mylin sheath
Thought process
Bal
Sensation
A

•Brain ⬇️ in volume: ⬇️ in neurons

•Myelinated axon length shortens
- slow delayed response to stimuli

• cognitive changes
-Slower thought process

•Mobility issues
-Poor bal

  • **Decreased sensation
    - Risk for injury
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25
Q

What is not completed in newborns at birth
-why is it needed

What changes do you see in a pregnant woman

A

Myelin sheath not completed at birth needed for a quick nerve transmission

PREG

  • changes in hypothalamus, pituitary hormones prolactin/oxytocin
  • increase pressure on nerves
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26
Q

Give situations of urgent assessment related to the neurological and mental status

A
  1. Acute change in mental status
    - A&OX4 suddenly confused
  2. History of seizure
    - protect head and extremities
  3. Change in PERRLA
  4. Assess paresis: progressing weakness or paralysis
  5. Unilateral extremity loss
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27
Q

What do you do if a patient who was A&O x4 suddenly becomes disoriented

What are types of disorientation

In this situation what do you want to check for in the patient

What do you want to assess for especially if there is no clear definitive cause of disorientation

A

If patient A&Ox4 suddenly becomes disoriented ACTIVATE RAPID RESPONSE

disorentation:

  • confused
  • stupor: not conscious not arousable
  • coma

Check AVPU

Assess for

  • toxins/viruses
  • vaccinations
  • pesticides
  • spider/snake/mosquito bites



28
Q

Abnormal body positions:

Describe deCORticate

What does decorticate posture indicate as far as injury

A

deCORticate = flexor

  • clinched fish bent arms on chest
  • plantar flexed

Decorticate posture indicates damage to cerebral cortex (path of brain and spinal cord) 

29
Q

Abnormal body positions:

Describe dEcErEbratE

What does decerebrate position indicate

A

dEcErEbratE = Extensory

-Extended body E hands
-plantar flexed

dEcErEbratE indicates damage to mid brain/upper ponds
SEVERE BRAIN INJURY





30
Q

 abnormal body positions:

Describe HEMIplagia

What does HEMIplagia arise from

A

HEMI= SEMIplagia

-unilateral loss of sensation/motor strength

HEMI (SEMI)plagia arises from stroke

31
Q

What does the Glasgow coma scale evaluate

What are the three areas of assessment within the Glasgow coma scale

What do the point system indicate

A

GCS assesses level of consciousness

Assessment areas: GCS= EVM
1. Eye-opening
2 verbal response
4. Motor function

 Point system
15-12: normal
9: being intubated
5: coma
3: deep coma
32
Q

 What are acute assessments that can be done for neurological assessment

A

GCS
PERRLA
Extremity strength
-Lift extremity and let drop see if patient can hold limb up
Sensation were gag reflex/ corneal reflex

33
Q

 what kind of sensation would you assess neurologically

When would you opt for the gag/ corneal reflex instead of sensation

Describe the corneal reflex
What are normal findings

A

Sensations include

  • sternal rub
  • nail

Only do sensation if patient CAN communicate if unconscious do gag/corneal reflex

Corneal reflex:
- tested by touching patiets cornea or eyelashes
• blinking = intact

34
Q

What is another name for dolls eyes

Who and How do you perform technique

What are normal findings and what do they indicate

A

Dolls eyes a.k.a. Occulocephalic reflex

Technique: in coma patients

  • hold upper eyelids open
  • quickly turn patient’s head

Norm:( -)
Eyes moving opposite direction of head
= Intact brain stem

35
Q

What is the Cushing’s reflex and what does it result in

A

Cushing’s reflex: nervous system response to increased ICP resulting in Cushing’s triad

36
Q

Give the components (signs) to Cushing’s triad and what they indicate

A

Cushing’s triad signs

  • ⬆️ICP
  • ⬆️SBP
  • ⬇️ in pulse and resp rate

Cushing’s triad Indicates brainstem compression

37
Q

If a patient presents with increased ICP /

Brain herniation how are pupils going to look

A

With increased ICP/ brain herniation pupils will be sluggish

38
Q

What is our goal in the neurological and mental status assessment

A

Our goal is to identify likelihood of developing or experiencing consequences of neurological neurovascular disease

39
Q

When assessing risk factors who do we refer to if the patient is not reliable

what do we want to know about past medical history

what is the role of seizure medications

A

If the patient is not reliable refer to a secondary source

We want to know about any CVA, head/cord injuries, seizure history or meningitis

Which seizure medications we wanna know if they are within therapeutic levels

40
Q

For risk reduction health promotion what are our health goals in relation to the neurological and mental status assessment

A

Prevent disease

Identify difficulties early

Reduce complication

41
Q

For risk reduction and health promotion what are the two main focuses in risk reduction on

A

 1. Stroke prevention

  • decrease weight/
  • decrease HTN/Dm/cholesterol/smoke
  • increase physical activity
  1. Injury prevention
    - Use a helmet
    - use a seatbelt
    - avoid head injuries with alcohol and drugs
42
Q

Give common neurological symptoms

A

Headache

Limb/unilateral weakness

Involuntary movements/tremors

Bal/coordination difficulties

Dizziness, vertigo, difficulty swallowing

** intellectual changes speech language difficulties

  •  change and taste, touch, smell
  • Blurred vision, lost vision, lost hearing, tinnitis
43
Q

What do you want to test for if patient is having speech and language difficulties and how

(1 very specific word)

A

If speech and language difficulties test for aphasia

: loss of ability to understand/express speech

-memory test, cognition tests

44
Q

What does it mean if a patient has a SUDDEN loss of smell/touch/taste

A

Efficient has sudden loss of smell/touch/taste assess for brain tumor

45
Q

What can cause paralysis

Give signs and symptoms of paralysis



A

Paralysis can be caused by:

  • STROKE
  • spinal injury
  • neuromuscular disease

S&s:

  • decrease motor function
  • Flacidity
46
Q

What is 4 extremity paralysis called

What is leg paralysis called

A

4 extremity paralysis: quadriplegia

Leg paralysis: paraplegia

47
Q

What can cause a tic

Give sign and symptoms for tic

A

tic can be caused by:
-Tourette’s
-Side effect of psychotropic (psych) meds
-amphetamines

S&S:
• Brief repetitive but irregular movement

48
Q

What can cause dystonia

What are signs and symptoms of dystonia

A

Dystonia can be caused by:
-use of psych meds

S & S:
-slow incoherent trunk twisting and twisting posture

49
Q

What culture population was exposed to pesticides and what do they develop because of the pesticides

A

Mexicans were exposed to pesticides and developed neurological symptoms because of the pesticides

50
Q

When can you integrate the Nuro exam

 give a few examples as to hell

A

You can integrate the neuroexam well taking health history

  • LOC
  • AVPU
  • GCS
  • knowledge/memory questions
51
Q

What is stereognosis

How do you test it

A

Stereognosis: done to identify objects

Technique:

  • have patient close eyes
  • place key, paperclip, coin in patient’s hand
  • have patient identify object
52
Q

What does Graphesthesia test

and how do you test it

A

Graphesthesia tests sensory function

Technique:

  • have patient close eyes
  •  draw # on palm
  • have patient ID #drawn
53
Q

What does the finger to nose target test and how do you test it on a patient

A

Finger to nose target evaluates sensory function

Technique:

  • put your finger out
  • have patient touch your finger then touch their nose
  • move your finger around
54
Q

What does it mean to note any asterixis

When would asterixis be present what would be elevated

A

Noting asterixis means noting slapping of wrist uncontrollably

Asterixis would be present with alcoholic hepatic encephalopathy and you wiuld note ⬆️ amonia levels

55
Q

Give the DTRs

Give the DTR scale

A

DTRs:
-bicep tricep patella Achilles

Scale:
4+: very brisk
3+: brisker than average
2+:normal
1+: diminished
0: no reflex
56
Q

Name your superficial reflexes

A

Abdominal
Scrotal
Babinski
Anal reflex

57
Q

 how do you complete the Babinski

What are normal findings
What are abnormal findings
What is the special consideration within findings

A

Babinski technique:
-stroke lateral aspect of patient’s Sole

(-)Normal finding: toes curl or no response

(+)Abnormal finding: great toe extends other toes fanout

Special consideration within findings:
-children UP TO 2 yoa May have positive Babinski sign and that is normal

58
Q

How do you conduct vibration sensation

A

Technique:

  • Close patient’s eyes
  • Activate tuning fork place on each tone
  • patient will see if they feel sensation
59
Q

What are some of the most common lifespan considerations for your older population

A

Slower thought, memory, reflexes

CNS atrophy

60
Q

How do you assessfor meningitis (signs)

 explain the Brodinski and Kernig’s sign

A

Headache
Fever
Nuchal rigidity

  • Brudzinski sign: positive resistance (pain) in neck with flexion of hips and knees
  • Kernig sign : pain in lower posterior when hips are flexed and neck is straightened
61
Q

What do you want to assess in an unconscious patient

A

In an unconscious patient assess four:

  • dolls eyes
  • gag reflex
  • corneal reflex
  • Babinski
62
Q

What are signs and symptoms of brain herniation

A
  1. Ipsilateral pupil dilation:
    pupil sluggishly reactive indicates worsening neurological status
    
  2. Irregular slow breathing
63
Q

 after doing an MRI preforming angiography requiring lumbar puncture

How long was the patient’s stay bedrest

What happens if the patient still has a headache

What does a persistent headache mean

A

After lumbar puncture patient must be bed rest 6 to 8 hours

If patient displays headache bedrest required for 24 hours plus fluids

If persistent headache it indicates a CSF leak

64
Q

After a lumbar puncture That results in CSF leak what is done to clot and seal the preparation

A

After lumbar puncture with known CSF leak do blood patch

Blood patch: is personal blood introduced to the epidural space that will clot and seal the perforation

65
Q

Give common lab and diagnostic tests

A

EEG test brain electrical activity

CSF spinal procedures

66
Q

Give nursing outcomes related to the neurological and mental status assessment

A

Patient cares for both sides of body and keeps affected side safe

Patient improved motor function, become independent with activities of daily

67
Q

Give nursing interventions related to the neurological and mental status assessment

A

Assess neurological and mental status as ordered inform Dr of changes

Orient patient to time place in person frequently

Health Assessment (20 decks)

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