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U of R SCHOOL OF NURSING > CLASS 3 - NEUROLOGICAL ASSESSMENT > Flashcards

CLASS 3 - NEUROLOGICAL ASSESSMENT Flashcards

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1
Q

CNS COMPONENTS

A
  • Brain

- Spinal cord

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2
Q

PNS COMPONENTS

A
  • 12 cranial nerves

- 31 pairs of spinal nerves

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3
Q

BRAIN COMPONENTS

A
  • Frontal lobe
  • Temporal lobe
  • Parietal lobe
  • Occipital lobe
  • Cerebellum
  • Brain stem
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4
Q

FRONTAL LOBE ACTIONS

A
  • Personality
  • Behavior
  • Intelligence
  • Emotion
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5
Q

TEMPORAL LOBE ACTIONS

A
  • Smell
  • Taste
  • Hearing
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6
Q

PARIETAL LOBE ACTIONS

A
  • Sensation
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7
Q

OCCIPITAL LOBE ACTIONS

A
  • Visual
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8
Q

CEREBELLUM ACTIONS

A
  • Motor

- Balance

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9
Q

BRAIN STEM ACTIONS

A
  • Autonomic nervous system
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10
Q

SPINAL CORD COMPONENTS

A
  • Extends 1st cervical vertebrae to the 1st lumbar vertebrae
  • Protected by the spinal vertebrae
  • Facilitates communication between the brain and periphery
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11
Q

SPINAL NERVE COMPONENTS

A
  • 31 pairs of spinal nerves
  • 8 cervical
  • 12 thoracic
  • 5 lumbar
  • 5 sacral
  • 1 coccygeal
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12
Q

CRANIAL NERVE COMPONENTS

A
  • Nerves that emerge directly from the brain - Divided based on specific functions
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13
Q

TYPES OF NEUROLOGIC ASSESSMENT

A
  • Screening neurologic exam
  • Complete neurologic exam
  • Neurologic recheck exam
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14
Q

PAST MEDICAL HISTORY ASSESSMENT

A
  • Hypertension
  • Seizures
  • Headaches
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15
Q

PERSONAL/SOCIAL HISTORY ASSESSMENT

A
  • Environmental hazards

- Exposure to insecticides, lead, radiation

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16
Q

LIFESTYLE/HEALTH PRACTICES HISTORY ASSESSMENT

A
  • Diet/exercise
  • Smoking/alcohol or substance abuse
  • Safety practices
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17
Q

FAMILY HISTORY ASSESSMENT

A
  • Hypertension
  • Stroke
  • Cancer
  • Cardiac/renal disease
  • Bleeding disorders
  • Seizure disorders
  • Brain tumors
  • Neurological disorders (Alzheimer’s, dementia, Parkinson’s, ALS)
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18
Q

REVIEW OF SYSTEMS ASSESSMENT

A
  • Headaches, trauma, dizziness, fainting, loss of balance
  • Weakness, numbness, tingling
  • Visual disturbance, double vision photophobia
  • Difficulty with swallowing/speaking
  • Motor deficit, incontinence
  • Memory, thought process, speech, mood, or personality changes
  • Seizures, tremors
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19
Q

RISK FACTORS FOR NEUROLOGIC IMPAIRMENT

A
  • Hypertension*
  • Chronic atrial fibrillation and flutter
  • Obesity*
  • Sedentary life-style*
  • Smoking tobacco products*
  • Stress*
  • Increased levels of serum cholesterol, lipoproteins, and triglycerides*
  • Use of oral contraceptives in high-risk women*
  • Family history of diabetes mellitus, CVD, hypertension, increased serum cholesterol levels
  • Congenital cerebrovascular anomalies
  • Modifiable risk factors - Health Promotion Opportunities
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20
Q

PHYSICAL EXAMINATION ASSESSMENT

A
  • Mental status: LOC, speech, cognitive, orientation, memory function, emotional status
  • Glasgow coma scale
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21
Q

T/F: Level of consciousness is the most sensitive indicator of neurologic deterioration

A
  • True
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22
Q

ALERTNESS LOC EXAMINATION ASSESSMENT

A
  • Speak to patient in a normal tone of voice

- Alert patient opens eyes, looks at you, responds fully and appropriately to stimuli

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23
Q

LETHARGY LOC EXAMINATION ASSESSMENT

A
  • Speak to the patient in a loud voice
  • Call the patient’s name or ask “how are you?”
  • Patient appears drowsy but opens eyes and looks at you
  • Responds to questions then falls asleep
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24
Q

OBTUNDATION LOC EXAMINATION ASSESSMENT

A
  • Shake patient gently
  • Patient opens eyes and looks at you
  • Responds slowly and somewhat confused
  • Alertness and interest are decreased
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25
Q

STUPOR LOC EXAMINATION ASSESSMENT

A
  • Apply a painful stimulus (pinch tendon)
  • Arouses from sleep only after painful stimuli
  • Responses slow or absent
  • Lapses into unresponsive state when stimulus ceases
  • Minimal awareness
26
Q

COMA LOC EXAMINATION ASSESSMENT

A
  • Apply repeated painful stimuli
  • Unarousable with eyes closed
  • No evident response to inner need or external stimuli
27
Q

GLASGOW COMA SCALE

A
  • Objective assessment that defines level of consciousness by giving it a numeric value
  • Divided into: eye opening, verbal response, motor response
  • Monitors for trends of neurologic deterioration
  • Minimum score = 3
  • Maximum score = 15
  • Coma = < 8
28
Q

CRANIAL NERVE I ASSESSMENT ASSESSMENT

A
  • OLFACTORY

- Occlude each nostril and test different smells

29
Q

CRANIAL NERVE II ASSESSMENT

A
  • OPTIC
  • Test visual acuity with Snellen chart/card
  • Inspect fundi
  • Screen visual fields by confrontation
30
Q

CRANIAL NERVE III, IV, VI ASSESSMENT

A
  • OCULOMOTOR, TROCHLEAR, ABDUCENS
  • Inspect pupils
  • Test extra ocular movements in 6 directions of (EOM’s)
  • Test convergence (corneal light reflex)
31
Q

CRANIAL NERVE V ASSESSMENT

A
  • TRIGEMINAL
  • Palpate temporal and masseter muscles while patient is clenching
  • Light touch on forehead, cheek and jaw
  • Sharp and dull sensation on forehead, cheek and jaw
32
Q

CRANIAL NERVE VII ASSESSMENT

A
  • FACIAL
  • Assess for asymmetry, tics, abnormal movements
  • Raise eyebrows
  • Frown
  • Close eyes tightly
  • Smile
  • Grimace
  • Puff both cheeks
33
Q

CRANIAL NERVE VIII ASSESSMENT

A
  • ACOUSTIC

- Test hearing by: whisper test, weber, and rinne test

34
Q

CRANIAL NERVE IX & X ASSESSMENT

A 
- GLOSSOPHARYNGEAL, VAGUS
Assess if voice hoarse
- Say "AH"
- Gag reflex
- Assess swallow
35
Q

CRANIAL NERVE XI ASSESSMENT

A
  • SPINAL
  • Assess strength
  • Patient shrugs shoulders up against your hands
  • Contraction of opposite sternocleidomastoid muscle as patient forces head against your hand
36
Q

CRANIAL NERVE XII ASSESSMENT

A
  • HYPOGLOSSAL
  • Assess for symmetry, atrophy
  • Patient to protrude tongue and move side-to-side and up-and-down
37
Q

SENSORY SHARP/DULL ASSESSMENT

A
  • U/L & bi-lateral extremities able to distinguish sharp/light touch
  • Eyes closed
  • Start distally and prick area on both sides and ask if sensation is sharp or dull
38
Q

SENSORY LIGHT TOUCH ASSESSMENT

A
  • Light touch using cotton wisp and ask if patient feels touch
39
Q

SENSORY VIBRATORY SENSE ASSESSMENT

A
  • Tap 128 Hz tuning fork on the DIP joint of the patient’s finger
  • “What do you feel?”
  • “Tell me when it stops”
40
Q

DISCRIMINATIVE SENSATION ASSESSMENT FACTORS

A
  • Stereognosis
  • Graphesthesia
  • 2-Point discrimination
  • Localization
  • Extinction
41
Q

STEROGNOSIS ASSESSMENT

A
  • Place familiar object in patient’s hand and ask to identify object
42
Q

GRAPHESTHESIA ASSESSMENT

A
  • Outline a number in the patient’s palm and ask to identify number
43
Q

TWO-POINT DISCRIMINATION ASSESSMENT

A
  • Using two ends of an opened paper-clip, touch finger pad in two places simultaneously
  • Ask the patient to identify 1 or 2 touches
44
Q

LOCALIZATION ASSESSMENT

A
  • Touch a point on the patient’s skin and ask the patient to point to that spot
45
Q

EXTINCTION ASSESSMENT

A
  • Touch 1 or 2 points on the patient’s skin and ask them to tell you where you pointed
46
Q

MOTOR FUNCTION ASSESSMENT FACTORS

A
  • Balance, gait, coordination
  • Romberg test
  • Pronator drift
  • Rapid alternating movements (RAM)
  • Finger-to-nose or finger-to-finger
  • Heel-to-shin
47
Q

BALANCE, GAIT, COORDINATION ASSESSMENT

A
  • Have patient walk across room
  • Walk heel-to-toe
  • Walk on toes then on heels
  • Hops in place
48
Q

ROMBERG ASSESSMENT

A
  • Have patient stand with feet together and arms at sides
  • Close eyes and stand for 20-30 seconds
  • Loss of balance = positive test
  • Always be guarding in case patient starts to sway!
49
Q

PRONATOR DRIFT ASSESSMENT

A
  • Have patient stand with feet together and arms straight forward, palms up
  • Close eyes for 20-30 seconds and examiner taps arms briskly downward
  • Pronation and downward drift of the arm = positive test
50
Q

RAPID ALTERNATIVE MOVEMENTS ASSESSMENT

A
  • Patient turns hand rapidly over and back on thigh
  • Taps tip of index finger rapidly on distal thumb
  • Taps ball of foot rapidly on your hand
51
Q

FINGER-TO-NOSE ASSESSMENT

A
  • Patient touches nose then your index finger as you move it different positions
52
Q

HEEL-TO-SHIN ASSESSMENT

A
  • Patient moves heel from opposite knee down the shin to the big toe and back up
53
Q

DEEP TENDON REFLEX ASSESSMENT FACTORS

A
  • Biceps
  • Triceps
  • Brachioradialis
  • Patellar
  • Achilles
  • Plantar Response (+/- Babinski)
  • Assess for Clonus
  • Graded 0 to 4+ scale
54
Q

0 - 4+ DEEP TENDON GRADING SCALE

A
  • 4+ : Very brisk, hyperactive, with clonus
  • 3+ : Brisker than average, but not necessarily indicative of disease
  • 2+ : Average; normal
  • 1+ : Somewhat diminished; low normal
  • 0 : No response
55
Q

BICEPS TENDON ASSESSMENT

A
  • Place thumb on palpated biceps tendon

- Strike thumb with a brisk, direct movement

56
Q

TRICEPS TENDON ASSESSMENT

A
  • Palpate triceps tendon and strike with a brisk, direct movement
57
Q

BRACHIORADIALIS TENDON ASSESSMENT

A
  • Hold thumb of hand you are planning to test (helps relax wrist)
  • Strike right below the bony protrusion on the wrist
  • Can feel the thumb vibrate
58
Q

PATELLAR TENDON ASSESSMENT

A
  • Strike the patellar tendon with a brisk, direct movement
59
Q

ACHILLES TENDON ASSESSMENT

A
  • Hold the foot in dorsiflexion and strike the achilles tendon directly
60
Q

PLANTAR RESPONSE ASSESSMENT

A
  • Drag of object in a j motion starting at the heel on the lateral side, ending at the big toe
    Curling in of toes (normal)
  • Fanning out of toes (abnormal)
61
Q

CLONUS

A
  • Tested when the reflexes are hyperactive

- Rapid, rhythmic contractions of the calf muscle and movement of the foot

62
Q

FURTHER NEUROLOGIC ASSESSMENT

A
  • Mental status changes or change from baseline
  • Known or suspected brain lesion (stroke, tumors, trauma)
  • Memory deficits or confusion
  • Vague behavioral complaints from friends or family
  • Aphasia
  • Irritability
  • Motor or sensory deficits

U of R SCHOOL OF NURSING (12 decks)

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