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Block 2 Week 8 Neurological > DONE: Neurological Assessment & Diagnostic Testing > Flashcards

DONE: Neurological Assessment & Diagnostic Testing Flashcards

0
Q

Decerebrate posturing accentuated by pain [extensor response: adduction of arm, internal rotation of shoulder, pronation of forearm and extension at elbow, flexion of wrist and fingers, leg extension, plantarflexion of foot]
This is what grade for motor responses on the Glasgow Coma Scale?

A

2

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1
Q

Withdrawal from pain [Absence of abnormal posturing; unable to lift hand past chin with supra-orbital pain but does pull away when nailbed is pinched]
This is what grade for motor responses on the Glasgow Coma Scale?

A

4

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2
Q

Oriented. [Patient responds coherently and appropriately to questions such as the patient’s name and age, where they are and why, the year, month, etc.]
This is what grade for verbal responses on the Glasgow Coma Scale?

A

5

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3
Q

No motor response.

This is what grade for motor responses on the Glasgow Coma Scale?

A

1

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4
Q

Decorticate posturing accentuated by pain [flexor response: internal rotation of shoulder, flexion of forearm and wrist with clenched fist, leg extension, plantarflexion of foot]
This is what grade for motor responses on the Glasgow Coma Scale?

A

3

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5
Q

Eye opening in response to pain stimulus.

This is what grade for eye movement on the Glasgow Coma Scale?

A

2

IMPORTANT: A peripheral pain stimulus, such as squeezing the lunula area of the patient’s fingernail is more effective than a central stimulus such as a trapezius squeeze, due to a grimacing effect.

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6
Q

Eyes opening spontaneously.

This is what grade for eye movement on the Glasgow Coma Scale?

A

4

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7
Q

Localizes to pain

This is what grade for motor responses on the Glasgow Coma Scale?

A

5

IMPORTANT: Purposeful movements towards painful stimuli; Ex. brings hand up beyond chin when supra-orbital pressure applied.

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8
Q

Eye opening to speech.

This is what grade for eye movement on the Glasgow Coma Scale?

A

3

IMPORTANT: Not to be confused with the awakening of a sleeping person these patients receive a score of 4 NOT 3.

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9
Q

Confused. [The patient responds to questions coherently but there is some disorientation and confusion.]
This is what grade for verbal responses on the Glasgow Coma Scale?

A

4

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10
Q

No verbal response.

This is what grade for verbal responses on the Glasgow Coma Scale?

A

1

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11
Q

Obeys commands [The patient does simple things as asked.]

This is what grade for motor responses on the Glasgow Coma Scale?

A

6

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13
Q

No eye opening.

This is what grade for eye movement on the Glasgow Coma Scale?

A

1

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14
Q

Incomprehensible sounds. [Moaning but no words.]

This is what grade for verbal responses on the Glasgow Coma Scale?

A

2

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14
Q

Inappropriate words. [Random or exclamatory articulated speech, but no conversational exchange. Speaks words but no sentences.]
This is what grade for verbal responses on the Glasgow Coma Scale?

A

3

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15
Q

When the nurse assesses the pupillary response to light what are they looking for?

A

Monitoring whether the pupils respond Slowly or Briskly.

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16
Q

Is the patient safe?
Do they land on their head a lot?
These questions are collecting what type of data?
What type of neurological assessment is this?

A

Subjective Data - Assessment

Study Tip: This can be a sign of a neurological disease process.

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17
Q

GCS 8-12

What does this value indicate on the Glasgow Coma Scale?

A

Moderate COMA response

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18
Q

Does the patient have altered Sexual Activity?
These questions are collecting what type of data?
What type of neurological assessment is this?

A

Subjective Data - Assessment

Study Tip: This can be a sign of a neurological disease process.

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19
Q

What is the range for the VERBAL response on the Glasgow Coma Scale? How is it measured?

A

1-4

Measure from Oriented and conversing easily to unable to get a verbal response at all.

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20
Q

Explain what the Best Motor Response term LOCALIZED means in relation to the Glasgow Coma Scale?

A

Localized means that if pain is inflicted to the left hand the right hand would move to guard.

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21
Q

Assess Pupillary response:
- Assessing > What cranial nerve?
- Assess for equality in constriction
- Shine the light in each eye twice to test for both direct and consensual constriction.
These are included in what type of neurological assessment?

A

Cranial Nerve III

Bedside Neurological Checks

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22
Q

A dead body or patient in a DEEP COMA gets a Glasgow Coma Scale score of ___.

A

3

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23
Q

ALWAYS look at the ________ of you patient including their affect, mental status, posture, movements, and general demeanor when assessing neurological deficits.

A

overall appearance

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24
Q

_________ is not a good sign this means that the patient is about to herniate their brain which will cause them to damage their brain stem and not be able to maintain their vital signs. DO NOT let your patient get to this point so look for other neurological signs and symptoms before it reaches this level of severity.

A

Fixed and dilated pupillary response

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25
Q

Monitor Vital signs for trends
- This is controlled by the ______ which could indicate pressure changes in the brain.
These are included in what type of neurological assessment?

A

Brain Stem
Bedside Neurological Checks
Study Tip: This is IMPORTANT

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26
Q

Pinpoint pupils. This is an example of what type of pupillary response?

A

This occurs when there has been damage to the Pons or Drug Abuse.

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27
Q
  • Location of brain lesion: Reticular formation of the Medulla
  • Description: Completely irregular with some breaths deep and some shallow. Random, irregular pauses, and a slow rate.
    This is what common abnormal respiratory patterns associated with a coma?
A

Ataxic Breathing

28
Q

When you ask the patient if they have any s/sx of Neurological Disorders what are some COMMON symptoms of this type of disorders?

A 
Pain
Seizures
Dizziness and Vertigo
Visual Disturbances
Muscle Weakness
Any Abnormal Sensation
29
Q

Do they have uncontrolled hypertension?
Does the patient have altered Bowel/Bladder Function?
Does the patient have altered Cognition/Sensory Integration?
These are included in what type data collected during a neurological assessment?

A

Subjective Data - Assessment

Study Tip: This can be a sign of a neurological disease process.

30
Q

What would you assess for in a patients medication history related to neurological disorders?

A

Assess for use of Sedatives, Opiods, or mood elevating drugs because these can affect the nervous system.

31
Q
  • Location of brain lesion: Bilateral hemispheric disease or metabolic brain dysfunction.
  • Description: Cycles of hyperventilation and apnea / no breathing.
    This is what common abnormal respiratory patterns associated with a coma?
A

Cheyne-Stokes

32
Q
  • Location of brain lesion: Mid or Lower Pons
  • Description: Prolonged inspiratory phase or pauses alternating with expiratory pauses > Taking big breaths then not breathing at all.
    This is what common abnormal respiratory patterns associated with a coma?
A

Apneustic Breathing

33
Q

GCS 13-14

What does this value indicate on the Glasgow Coma Scale?

A

Minor COMA response

34
Q

ASK ARBOGAST? Name the 6 Diagnostic Tests used to diagnose Neurological Disorders and look inside the brain?

A 
Computed Tomography scan (CT)
Magnetic Resonance Imaging (MRI)
Electroencephalography (EEG)
Lumbar Puncture (LP)
Cerebral Angiogram
Myelogram
Study Tip: NONE OF THESE WERE DISCUSSED ON THE POWERPOINT Are they important?
35
Q 
Physical assessment Includes:
- General observation of client
- Reflex Function
- Review Mental status
- Sensory Function
- Assess Function of the Cranial Nerves each ONE individually
- Cerebellar Function
- Evaluate motor function
These are ALL included in what type data collected during a neurological assessment?
A

Objective Data - Physical Assessment

Study Tip: This can be a sign of a neurological disease process.

36
Q

Assess Respiratory pattern:
- Does the patient ____ breathing?
- Assess Respiratory Rate
These are included in what type of neurological assessment?

A

STOP
Bedside Neurological Checks
Study Tip: This is IMPORTANT

37
Q

The Respiratory System of the brain is located in and controlled by the Brain Stem changes in ______ which could indicate pressure changes in the brain.

A

Respiratory Patterns

38
Q
  • Location of brain lesion: Medulla or Lower Pons
  • Description: Clusters of breaths follow each other with irregular pauses between
    This is what common abnormal respiratory patterns associated with a coma?
A

Cluster Breathing

40
Q

Assess Motor function:
- Assess for equal strength, posture, and ____
These are included in what type of neurological assessment?

A

Gait

Bedside Neurological Checks

41
Q

GCS Less than 8

What does this value indicate on the Glasgow Coma Scale?

A

Severe COMA response

42
Q

Assess for presence of pain and headache:
-_______ onset or complaints of the worst headache of the patient’s life could indicate a problem occurring in the brain.
These are included in what type of neurological assessment?

A

Rapid

Bedside Neurological Checks

43
Q

What is the Glasgow Coma Scale used for?

A

It is used to assess Level Of Conciousness

44
Q

_________ is used to measure a patients responsiveness.

A

Glasgow Coma Scale /GCS

45
Q

Pupils that are round, equal, and react normally.

This is an example of what type of pupillary response?

A

Normal pupillary response

46
Q

ASK ARBOGAST? The LEFT eye is having a dilated pupillary response to a Compressed Cranial Nerve - III that means that the ______ cranial nerve is not working this could be related to what _______ and ________.

A

LEFT
Tumor
Swelling

47
Q 
Assess LOC using the Glasgow Coma Scale
Assess Pupillary response
Assess Respiratory patterns
Assess Motor function
Assess for presence of pain and headache
Assess for the presence of projectile vomiting not associated with nausea
Evaluate Vital signs for trends
These are ALL included in what type of neurological assessment?
A

This is a COMPLETE Bedside Neurological Check

48
Q

What is the range for the EYES response on the Glasgow Coma Scale? How is it measured?

A

1-4

Measured from Spontaneous eye opening to we cannot get them to open their eyes at all

49
Q

Patients who abuse morphine can have ______ as well.

A

Pinpoint pupils

50
Q

Bilateral dilated and fixed pupils. This is an example of what type of pupillary response?

A

This is an ominous sign that the patient is about to herniate their brain which will cause them to damage their brain stem and not be able to maintain their vital signs.

50
Q
  • Location of brain lesion: Brainstem between lower midbrain and upper Pons.
  • Description: Sustained regular and rapid breathing > Hyperventilation
    This is what common abnormal respiratory patterns associated with a coma?
A

Central Neurogenic Hyperventilation

51
Q

The ____ and the _____ help regulate the respiratory pattern because they control the Respiratory Center of the brain which is located in the ______.

A

Pons
Medulla
Brainstem

52
Q

Assess Function of the Cranial Nerves each ONE individually:
Evaluate motor function
- Assess grips, pushes, and pulls.
Cerebellar Function
- Does the patient have coordinated movement
These are included in what type data collected during a neurological assessment?

A

Objective Data - Physical Assessment

Study Tip: This can be a sign of a neurological disease process.

54
Q

Assess Respiratory Pattern:
- Assess for use of ______ muscles during breathing
- Assess the patient and determine what does the respiratory pattern look like?
These are included in what type of neurological assessment?

A

Accessory
Bedside Neurological Checks
Study Tip: This is IMPORTANT

55
Q

What is Flexor Posturing also called? Why is it called that?

A

DeCORticate
REMEMBER: Flexed Elbows. The hands move to the Core.
Study Tip: This is IMPORTANT

56
Q

Have the patient close eyes and touch their finger to their nose.
Sensory Function
- Sharp/Dull Test
- Can the patient tell whether their finger is up or down with eyes closed?
Reflex Function
These are included in what type data collected during a neurological assessment?

A

Objective Data - Physical Assessment

Study Tip: This can be a sign of a neurological disease process.

56
Q

Which is a worse diagnosis for your patient Extensor Posturing or Flexor Posturing?

A

Extensor Posturing is WORSE than the Flexor Posturing.

Study Tip: This is IMPORTANT

57
Q

Explain what the Best Motor Response term WITHDRAWS means in relation to the Glasgow Coma Scale?

A

Withdraws means that if pain is inflicted to the left hand the left hand will withdraw from the source of the pain.

58
Q

What is the range for the MOTOR response on the Glasgow Coma Scale? How is it measured?

A

1-6

Measured from Obeys all commands such as grips and pushes to no motor response

59
Q

Do they wear seat belts or helmets when riding a bike?
Does the patient enjoy jumping off of buildings?
These are included in what type data collected during a neurological assessment?

A

Subjective Data - Assessment

Study Tip: This can be a sign of a neurological disease process.

59
Q

What is the difference between a direct and a consensual pupillary response?

A
  • Direct: When you shine the light in the LEFT eye the LEFT eye should constrict
  • Consensual: When you shine the light in the RIGHT eye the LEFT eye should constrict as well.
59
Q

Dilated pupil. This is an example of what type of pupillary response?

A

Pupillary response to a

Compressed Cranial Nerve - III

59
Q

What is Extensor Posturing also called? Why is it called that?

A

DEcErEbratE
REMEMBER: Extremely extended posturing. Lots of E’s.
Study Tip: This is IMPORTANT

60
Q

Presence of projectile vomiting ____ associated with nausea
- This symptom is associated with increased intracranial pressure.
These are included in what type of neurological assessment?

A

NOT

Bedside Neurological Checks

62
Q

GCS 15

What does this value indicate on the Glasgow Coma Scale?

A

Best COMA Respone

64
Q

Assess LOC
- Use the Glasgow Coma Scale
- Changes in LOC indicate neurological changes.
These are included in what type of neurological assessment?

A

Bedside Neurological Checks

Study Tip: This is IMPORTANT.

66
Q

A patient who is awake and oriented would get a Glasgow Coma Scale score of ___.

A

15

67
Q

What score does a Flaccid patient get on the Glasgow Coma Scale?

A

This patient gets a GCS score of 1.

Study Tip: This is IMPORTANT

Block 2 Week 8 Neurological (14 decks)

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