Chapter 65 Neurological Assessment Flashcards
What is involved in a detailed neuro assessment?
▪️Mental status (cerebral function) ▪️Cranial nerve function ▪️Sensory function ▪️Motor function ▪️Reflexes
What is assessed during a mini neuro assessments?
▪️LOC ▪ Pupil size and response ▪️Verbal responsiveness ▪️Extremity strength and movement ▪️VS
What is included in a mental status assessment?
▪️LOC- change is a sensitive indicator of change in neuro status
▪️Appearance and behavior
▪️Speech
▪️Cognitive function
▪️Constructional ability- simple tasks and use of common objects
What are some common symptoms of neurological disorders?
Pain, seizures, dizziness and vertigo, visual disturbances, muscle weakness, and abnormal sensation
What assessments are included in a neuro assessment?
Assessing consciousness and cognition, mental status, intellectual function, thought content, emotional status, language ability, impact on lifestyle, level of consciousness, cranial nerve assessment
What details related to neurological disorders are included in the health history?
Onset, character, severity, location, duration, and frequency of symptoms and signs; associated complaints; precipitating, aggravating, and relieving factors; progression, remission, and exacerbation; and the presence or absence of similar symptoms among family members.
What is included in a sensory assessment?
Tactile sensation, superficial pain, temperature, vibration, and position sense (proprioception), examining reflexes
What are some age related structural and physiological changes to the nervous system?
A decrease in the number of synapses and neurotransmitters. Slowed nerve conduction and response time. Reduced cerebral perfusion and metabolism, leading to slower mental functions. Less efficient temperature regulation. Decrease in conduction velocity in peripheral nerves due to loss of myelin. Loss of visual acuity and hearing, taste bud atrophy, decreased sense of smell, decrease in deep tendon reflexes, altered sleep patterns such as reduced stage IV sleep, reduced or absent pupillary response, reduced nerve input into muscle leading to atrophy, dulled tactile sensations
What is included in a motor system assessment?
Motor ability, Muscle strength, balance and coordination
What can a CT scan be used to detect?
- Brain contusion
- Brain calcification
- Cerebral atrophy
- Hydrocephalus
- Inflammation
- Space occupying lesions (tumors, hematomas, abscesses)
- Vascular anomalies
What are the nursing considerations associated with CT?
Confirm pt isn’t allergic to iodine or shellfish.
Explain IV catheter will inject dye if contrast medium is used.
Explain that contrast medium may cause pt to feel flushed or have metallic taste in mouth.
*Explain to pt to lie still during test.
*Encourage pt to increase fluid after test to flush out dye.
What diagnostic tests are done with altered neuro function?
CT, MRI, PET Scan, SPECT, Cerebral Angiography, Myelography, Noninvasive Carotid Flow Studies, Transcranial Doppler, EEG, Electromyography (EMG), Nerve Conduction Studies, Evoked Potential Studies, Spinal Tap
What are some nursing consideration with MRI?
- Explain that procedure takes 1 1/2 hrs and has to stay still for 15-20 minute intervals
- Have pt remove all metallic items
- Ask pt if they experience claustrophobia and obtain Anxyolitics as needed
- Explain that the procedure is painless but can be loud and frightening and that pt can use earplugs
- Provide sedation, as ordered, to promote relaxation during test
What is PET Scan used for?
It’s used to reveal cerebral dysfunction associated with tumors, seizures, TIAs, head trauma, some mental illnesses, DAT, Parkinson’s Disease, and MS.
What are nursing considerations with PET Scan?
- Assure pt that test will not expose them to harmful levels of radiation
- Explain that test may require IV catheter insertion
