Exam 2 Neurological Disorders Flashcards
Physical Assessment of Neurological System includes (5)
1) Level of Consciousness
2) Motor Function
3) Sensation
4) Reflexes
5) Vitals
What do we use to assess LOC?
Range =
Best Score =
Glasgow Coma Scale
- Eyes opening
- Motor response
- Verbal response
3-15
15
Levels of Motor Function 0 = \+1 = \+2 = \+3 = \+4 = \+5 =
0 = no movement \+1 = slight movement \+2 = can raise extremity; but not lift it \+3 = can raise extremity; not against resistance \+4 = full ROM, less strength then normal \+5 = full ROM, full strength
Sensation
- Can they differentiate between?
Soft vs Sharp
Reflexes
- Babinski =
- Protective reflexes =
- extension of big toe
- brain stem
Vitals
- Cushings triad indicates =
Symptoms (3)
What should you do?
= herniation in progress
- Bradycardia, Bradypnea, Widened pulse pressure (wide gap btw systolic and diastolic)
- Call provider!
Normal Findings
1) GCS =
2) AO x ___
3) +__ strength in arms/legs bilaterally
4) Sensation ____ and ____
1) 15
2) x4
3) +5
4) Intake and Equal
Abnormal Findings
1) GCS =
2) AO =
3) +___ strength in arms bilaterally, +___ strength in legs bilaterally
4) Sensation =
1) 13
2) awake, alert, and oriented to person and place
3) +4, +5
4) cannot differentiate btw sharp vs. dull sensation
Spina Bifida =
Results in (3)
= Birth defect where neural tube fails to close as a fetus
1) Spina Bifida Occulta
2) Meningocele
3) Meninomyelocele
Causes of Spina Bifida
Unknown causes
Associated with lack of folic acid
Spina Bifida S/S
1) _____ ___ abnormalities
2) _____ near buttocks
3) H______
1) Neural tube abnormalities
2) Dimpling near buttocks
3) Hydrocephalus
Diagnosis of Spina Bifida when and with what?
Prenatally with Ultrasound
Spina Bifida Interventions
1) Prevention =
2) ____ control
3) ____ prep
Foods high in folic acid =
1) folic acid for child bearing age
2) Infection
3) Surgical
= dark leafy green vegetables, most fruits, potatoes, US grains are enriched with FA
Hydrocephalus =
= Enlargement of the ventricles due to increase in CSF
Cause of Hydrocephalus =
Due to (2)
Enlarged ventricles ->
= too much, or too little absorption of CSF
- head trauma, tumors/masses
- push out on brain -> enlarged head/fontanels
Hydrocephalus S/S
1) H____
2) ____, _____ eyes
3) _____ fontanels
4) ____ head circumference
5) _____ scalp veins
6) V______
7) _____ at later stages (unable to walk straight)
1) headache
2) Bulging, Sunsetting
3) Bulging
4) Increased
5) Dilated
6) Vomiting
7) Ataxia
Hydrocephalus Solution* =
- monitor for ____/____
- _____/____ is an emergency bc it may indicate?
- Temporary of Permanent?
VP shunt*
- malfunction/infection
- headache/fever, may indicate kinks, infection
- permanent (life long)
Hydrocephalus Nursing Interventions
1) ___ prep for vp shunt
2) Monitor head _____
3) Monitor for ___ activity
4) Careful _____ changes
5) Keep baby _____
1) Surgical prep
2) circumference
3) seizure
4) Position
5) calm
Cerebral Palsy =
Affects which muscles?
Non-progressive, permanent disability that affects movement and speech
Affects both voluntary and involuntary muscles
Cerebral Palsy Types
1) Not always associated with _______ ->
2) MRCP =
1) mental retardation -> fully cognitive but unable to speak/move properly
2) Mental Retardation Cerebral Palsy
Cerebral Palsy Diagnosis
- Often diagnosed when?
- May occur later in life after what?
- in first year of life d/t hypoxia at birth or in utero
- a hypoxic event
Cerebral Palsy S/S (3)
1) Spastic (stiff)
2) Dyskinetic (involuntary)
3) Ataxic (shaky)
Spastic sx in Cerebral Palsy
1) ____ - reflexia
2) ____ tonia
3) ____ spasticity
4) ___ walking
5) S_____
6) Continues to have =
1) Hyper-reflexia
2) Hypertonia (increased muscle tone)
3) Muscle spasticity
4) Toe walking
5) Scissoring
6) Neonatal reflexes
Dyskinetic sx in Cerebral Palsy
1) ____ movement
2) Trouble ______
1) Writhing
2) Speaking
