DONE: Neurological Assessment & Diagnostic Testing

Question 0

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?

Answer 0

2

Question 1

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?

Answer 1

4

Question 2

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?

Answer 2

5

Question 3

No motor response.

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

Answer 3

1

Question 4

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?

Answer 4

3

Question 5

Eye opening in response to pain stimulus.

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

Answer 5

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.

Question 6

Eyes opening spontaneously.

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

Answer 6

4

Question 7

Localizes to pain

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

Answer 7

5

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

Question 8

Eye opening to speech.

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

Answer 8

3

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

Question 9

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?

Answer 9

4

Question 10

No verbal response.

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

Answer 10

1

Question 11

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

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

Answer 11

6

Question 13

No eye opening.

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

Answer 13

1

Question 14

Incomprehensible sounds. [Moaning but no words.]

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

Answer 14

2

Question 14

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?

Answer 14

3

Question 15

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

Answer 15

Monitoring whether the pupils respond Slowly or Briskly.

Question 16

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?

Answer 16

Subjective Data - Assessment

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

Question 17

GCS 8-12

What does this value indicate on the Glasgow Coma Scale?

Answer 17

Moderate COMA response

Question 18

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

Answer 18

Subjective Data - Assessment

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

Question 19

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

Answer 19

1-4

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

Question 20

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

Answer 20

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

Question 21

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?

Answer 21

Cranial Nerve III

Bedside Neurological Checks

Question 22

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

Answer 22

3

Question 23

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

Answer 23

overall appearance

Question 24

_________ 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.

Answer 24

Fixed and dilated pupillary response

Question 25

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?

Answer 25

Brain Stem Bedside Neurological Checks Study Tip: This is IMPORTANT

Question 26

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

Answer 26

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

Question 27

- 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?

Answer 27

Ataxic Breathing

Question 28

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

Answer 28

``` Pain Seizures Dizziness and Vertigo Visual Disturbances Muscle Weakness Any Abnormal Sensation ```

Question 29

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?

Answer 29

Subjective Data - Assessment Study Tip: This can be a sign of a neurological disease process.

Question 30

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

Answer 30

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

Question 31

- 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?

Answer 31

Cheyne-Stokes

Question 32

- 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?

Answer 32

Apneustic Breathing

Question 33

GCS 13-14 | What does this value indicate on the Glasgow Coma Scale?

Answer 33

Minor COMA response

Question 34

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

Answer 34

``` 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? ```

Question 35

``` 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? ```

Answer 35

Objective Data - Physical Assessment Study Tip: This can be a sign of a neurological disease process.

Question 36

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

Answer 36

STOP Bedside Neurological Checks Study Tip: This is IMPORTANT

Question 37

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.

Answer 37

Respiratory Patterns

Question 38

- 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?

Answer 38

Cluster Breathing

Question 40

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

Answer 40

Gait | Bedside Neurological Checks

Question 41

GCS Less than 8 | What does this value indicate on the Glasgow Coma Scale?

Answer 41

Severe COMA response

Question 42

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?

Answer 42

Rapid | Bedside Neurological Checks

Question 43

What is the Glasgow Coma Scale used for?

Answer 43

It is used to assess Level Of Conciousness

Question 44

_________ is used to measure a patients responsiveness.

Answer 44

Glasgow Coma Scale /GCS

Question 45

Pupils that are round, equal, and react normally. | This is an example of what type of pupillary response?

Answer 45

Normal pupillary response

Question 46

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 ________.

Answer 46

LEFT Tumor Swelling

Question 47

``` 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? ```

Answer 47

This is a COMPLETE Bedside Neurological Check

Question 48

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

Answer 48

1-4 | Measured from Spontaneous eye opening to we cannot get them to open their eyes at all

Question 49

Patients who abuse morphine can have ______ as well.

Answer 49

Pinpoint pupils

Question 50

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

Answer 50

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.

Question 50

- 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?

Answer 50

Central Neurogenic Hyperventilation

Question 51

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

Answer 51

Pons Medulla Brainstem

Question 52

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?

Answer 52

Objective Data - Physical Assessment Study Tip: This can be a sign of a neurological disease process.

Question 54

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?

Answer 54

Accessory Bedside Neurological Checks Study Tip: This is IMPORTANT

Question 55

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

Answer 55

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

Question 56

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?

Answer 56

Objective Data - Physical Assessment Study Tip: This can be a sign of a neurological disease process.

Question 56

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

Answer 56

Extensor Posturing is WORSE than the Flexor Posturing. | Study Tip: This is IMPORTANT

Question 57

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

Answer 57

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

Question 58

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

Answer 58

1-6 | Measured from Obeys all commands such as grips and pushes to no motor response

Question 59

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?

Answer 59

Subjective Data - Assessment Study Tip: This can be a sign of a neurological disease process.

Question 59

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

Answer 59

- 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.

Question 59

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

Answer 59

Pupillary response to a | Compressed Cranial Nerve - III

Question 59

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

Answer 59

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

Question 60

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

Answer 60

NOT | Bedside Neurological Checks

Question 62

GCS 15 | What does this value indicate on the Glasgow Coma Scale?

Answer 62

Best COMA Respone

Question 64

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

Answer 64

Bedside Neurological Checks | Study Tip: This is IMPORTANT.

Question 66

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

Answer 66

15

Question 67

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

Answer 67

This patient gets a GCS score of 1. Study Tip: This is IMPORTANT