Exam 4 Flashcards
Nociceptive pain (NP)
o specialized nerve endings located in the cutaneous and deep musculoskeletal tissue that detect painful stimuli from the periphery and communicate this information to the CNS
o Nociceptors carry pain signal to the CNS by two primary sensory (afferent) fibers: Aδ and C fibers
o NP starts outside of the nervous system from actual or potential tissue damage. It has 4 phases.
Know the 4 phases of Nociception
o Transduction
o Transmission
o Perception
o Modulation
Transduction
noxious stimulus takes place in periphery
Transmission
pain impulse moves from spinal cord to brain
Perception
conscious awareness of painful sensation
Modulation
inhibition of pain message
neuropathic pain (NEP)
o results from an abnormal processing of the pain message from an injury to nerve fibers
o Pain is described as: Constant dull ache, Burning, Stabbing, Electric shock, Tingling
o Much more difficult to assess and treat
o Nociceptive pain can develop into Neuropathic pain if poorly controlled
what can cause neuropathic pain
diabetes mellitus, shingles (herpes zoster), HIV/AIDS, sciatica, trigeminal neuralgia, phantom limb pain, chemotherapy, stroke, multiple sclerosis, tumor
visceral pain
originates from larger internal organs (stomach, intestine, gallbladder, pancreas); described as dull, deep, squeezing, or cramping
pain impulses transmitted along the autonomic nervous system (ANS)
deep somatic pain
comes from blood vessels, joints, tendons, muscles, bone; may result from pressure, trauma, or ischemia
- pain feels aching or throbbing
cutaneous pain
derived from skin surface and subQ tissues
pain feels sharp, superficial, burning
referred pain
pain felt in a site different from pain origin (pain is referred to where the organ was located in fetal development)
(Ex. Appendix felt in umbilical region)
Acute pain
Short-term self limiting; often follows a predictable trajectory and dissipates after an injury heals
-Serves as a protective measure
-Ceases after an injury heals
ex. surgery, trauma, kidney stones
Chronic (persistent) pain
Greater than 6 months
- malignant or non-malignant
Recognize nonverbal behaviors associated with pain
guarding, grimacing, moaning, agitation, restlessness, stillness, diaphoresis, change in vital signs
developmental variations in pain for the aging adult
pain is a common experience among 65yo and older, but is not normal
Understand the physiologic effect of pain on vital signs
cardiac (tachycardia, increased BP)
pulmonary (hypoventilation, hypoxia, atelectasis)
gastrointestinal (nausea, vomiting)
renal (oliguria, urinary retention)
musculoskeletal (spasms, joint stiffness)
central nervous system (fear, anxiety, fatigue)
immune (impaired wound healing)
developmental variations in pain for the infant
changes in facial activity and body movements may help in deciphering pain in infants; CRIES score is a tool for postoperative pain in neonates; FLACC is another tool used
how to test cerebellum
-Rhomberg’s: swaying side to side while standing and eyes closed
-Finger-to-nose (“point to point”) testing
-Heel-knee-shin
-Rapid Alternating Movements in UE & LE
pain rating scales for children
faces pain scale or oucher scale, CRIES scale, FLACC scale
Reinforcement for patellar reflex
Crossing arms
pain rating scales for adults
PQRST
initial pain assessment
brief pain inventory
short-form McGill Pain questionnaire
pain-rating scales
numeric rating scales
verbal descriptor scale
visual analogue scale
descriptor scale
the normal changes in mental status and neurological findings frequently seen with aging
- Expect slower response
- Observe for tremors
- Peripheral sensation may be slightly diminished
- DTRs less brisk
CRIES scale
crying, requires O2, increased vital signs, expression, sleeplessness
what subjective data do adults have for the neuro system
headache, head injuries, weakness, seizures, dizziness/vertigo, tremors, weakness, incoordination, numbness/tingling, trouble swallowing
FLACC scale
face, legs, activity, cry, consolability
what subjective data do children have for the neuro system
prenatal history, family history, balance, reflexes, if baby is pre-term, developmental issues/learning disabilities, environmental exposure (lead), if they play sports (concussion)
PAINAD scale
pain assessment in advanced dementia
how to perform objective examination
metal status, cranial nerves, motor system (tandom walk), sensory systems, reflexes, glasgow coma scale
initial pain assessment
asks the pt to answer 8 questions concerning location, duration, quality, intensity, and aggravating/relieving factors
types of neurological screening
screening neurologic exam, complete neurologic exam, neurologic check
numeric rating scale
asks a pt to choose a number that rates the level of pain for each painful site; 0 is no pain 10 is excruciating pain
who do we use a screening neurologic exam for
healthy people with no significant history
what is the PQRST method of pain assessment?
provocation/palliation, quality/quantity, region/radiation, severity scale, timing
who do we use a complete neurologic exam for
people who have neurologic concerns (headache, weakness, loss of coordination)
who do we use a neurologic check on
hospital pt with head trauma or neurological defect (stroke, seizure, brain surgery); done frequently (abt every 15 min)
How do we test for mental status
Using ABCT (appearance, behavior, cognitive abilities, and thought processes and perceptions
What do we look for in appearance test
posture, dress, grooming, and hygiene
What do we look for in behavior test
LOC, facial expression, speech, and mood/affect
What do we look for in cognitive abilities test
Orientation (person place and time (not clock time)). Recent memory (what did you eat this morning), and remote memory (who was our previous president).
What do we look for in a thoughts processes and perceptions test
Reasoning (what does looking for a needle in a haystack mean), and judgement (ask about job plans, family obligations and plans for future)
Cranial Nerve 1
Olfactory nerve
Sensory
-(not tested routinely)
-Check patency of nares!!
-With person’s eyes closed, occlude one nostril and present familiar aromatic substance, e.g., coffee, orange, vanilla, soap, or peppermint
-Normally, person can identify an odor on each side of nose; normally decreased with aging; any asymmetry in sense of smell is important
-Abnormal: anosmia – upper respiratory infection, tobacco or cocaine use, frontal lobe lesion
Cranial Nerve 2
Optic Nerve
Motor
Test visual acuity:
-Describe use of Snellen Chart, 20/200
-Demonstrate use of Hand Held Vision Screener and interpret
Cranial Nerve 3
Oculomotor
Motor
-PERRLAC: Check pupils for equal size/round, reactive (direct and consensual), accommodation, and convergence
-Abnormal with tumor/lesion, increased intracranial pressure (unilateral dilation, nonreactive pupil), neuromuscular disease
Cranial Nerve 5
Trigeminal Nerve (Facial)
Motor and Sensory
*Motor function: palpating temporal and masseter muscles as person clenches teeth, try to separate jaws by pushing down on chin
*Sensory function: with person’s eyes closed, test light touch sensation by touching a cotton wisp to forehead, cheeks, and chin
Cranial Nerve 7
Facial Nerve
Motor and Sensory
Motor function:
-Note mobility and facial symmetry as person responds to requests to smile, frown, close eyes tightly (against your attempt to open them), lift eyebrows, show teeth, puff cheeks
-Abnormal in stroke or Bell Palsy
Sensory function: (not tested routinely)
-Test only when you suspect facial nerve injury
-Describe, test sense of taste by applying cotton applicator covered with solution of sugar, salt, or lemon juice to tongue and ask person to identify taste
-Anterior 2/3 of tongue
Cranial Nerve 8
Acoustic Nerve (Vestibulocochlear)
Sensory
Test hearing acuity by ability to hear spoken word whisper test
Cranial Nerve 11
Spinal Accessory Nerve
Motor
-Symmetry of muscles of neck/shoulders
-Check equal strength by asking person to rotate head against resistance applied to side of chin
-Ask person to shrug shoulders against resistance
-These movements should feel equally strong on both sides
-Abnormal – stroke (opposite side of lesion)
Cranial Nerve 12
Hypoglossal Nerve
Motor
-Note forward thrust in midline as person protrudes tongue
-Ask person to say “light, tight, dynamite,” and note that lingual speech (sounds of letters l, t, d, n) is clear and distinct
-Abnormal – tongue deviates to side of lesion/stroke
how to test motor system
Balance Tests
- Gait (normal and tandem)
- Romberg Test – 20 seconds. State results
how to test sensory system
Peripheral Pain:
- Sharp/dull extremities
- Abnormal: peripheral neuropathy (diabetes, peripheral arterial disease)
what are reflexes and what are the four types of them
Reflexes: basic defense mechanisms of nervous system
-Involuntary
below level of conscious control permitting quick reaction to potentially painful or damaging situations
Four types of reflexes:
- Deep tendon reflexes (myotatic), e.g., knee jerk
. - Superficial, e.g., corneal reflex, abdominal reflex
- Visceral, e.g., pupillary response to light
- Pathologic (abnormal), e.g., Babinski’s reflex or extensor plantar reflex
Recognize the normal primitive reflexes seen in the infant
Have primitive reflexes resolved at normal time?Rooting – brush cheek (birth to 3 – 4 months)
Sucking – birth to 10 – 12 months
Palmar grasp - birth to 3 – 4 months
Babinski reflex – toes fan (positive Babinski) birth to about 2 years
Tonic neck
Moro Reflex
Placing and Stepping Reflex
Know how to assess LOC and the importance of doing such
Level of consciousness (change is earliest and most sensitive index of change in neurologic status), Orientation, Motor function - strength extremities (follow commands), facial movement, arm drift; Pupillary Response (PERRLAC); Vital Signs, including Glasgow Coma Scale
Spasticity
types of increased resistance that occur with central weakness
Paralysis
loss of ability to move and sometimes feel
Flaccidity
decreased muscle tone; muscle feels limp/soft/flabby
Rest tremor
when a person’s hands/legs shake when they are at rest; often only affects hands
Intention tremor
increases as an extremity approaches the endpoint of deliberate and visually guided movement (like when someone cannot feed themselves because their hand shakes so much upon completion of moving a spoon to their mouth)
Opisthotonos
when someone holds their body in an awkward position
Decorticate rigidity or posturing
flexion of arm, wrist, fingers; arm tight against thorax; lower extremity internal rotation
Decerebrate rigidity or posturing
upper extremities stiffly extended; palms pronated; teeth clenched; hyperextended back
What does the Central Nervous System consist of?
brain and spinal cord
Kinesthesia test
tests a person’s ability to perceive passive movements of the extremities; move fingers/toes up and down and ask pt to tell you which way it moved
Stereognosis test
tests pt ability to recognize objects by feeling their forms, sizes and weights; close pt eyes, place a familiar object into hand, ask them to identify
Graphesthesia test
tests pt ability to read a number or letter by having it traced in the skin; close pt eyes and using a blunt instrument trace a single digit into palm, ask them to identify
Perception test
test pt ability to distinguish two separate points on the skin; apply 2 points of percussion hammer (sharp/dull) on skin and have pt note different points
Romberg test (include what a negative and positive Romberg test means/indicates)
tests pt balance and posture; have pt stand with feet and arms together with eyes closed for 20 seconds and maintain balance/posture
6 reflexes tested in the Neurological System
biceps
triceps
brachioradialis
patella
achilles
plantar/babinski
Paraplegia
symmetric paralysis (two extremities)
Quadriplegia
paralysis of all four extremities
What is the primary purpose of the Glascow Coma Scale?
Used to asses a pt’s level of consciousness and assess functional state of the brain as a whole
*Monitor LOC over time (improving or deteriorating)
What is the highest and lowest score you can receive on the Glascow Coma Scale?
*Total Numeric value: highest 15, lowest 3, less than 7 coma
How do we get the Glascow Coma Scale score?
- Eye Opening: 1 - 4
- Motor Response: 1 - 6
- Verbal Response: 1 - 5
What does the finger to nose test allow assessment of?
assesses coordinated, smooth, skilled movement and fine motor function
an abbreviated mental status examination is generally conducted when
The interview process, frequently upon admission to the hospital. It is a 10 point test for rapidly assessing elderly patients for possibility of dementia
Deep tendon reflexes
- Reveals intactness of reflex arc at specific spinal levels
- Limb should be relaxed and muscle partially stretched
- Stimulate reflex by directing short, snappy blow of reflex hammer onto muscle’s insertion tendon
- Compare right and left sides: responses should be equal
Reflex response graded on 4-point scale
4 = very brisk, hyperactive with clonus, indicative of disease
3 = brisker than average, may indicate disease
2 = Average, normal
1 = diminished, low normal, or occurs with reinforcement
0 = no response
bicep reflexes
contraction of biceps muscle and flexion of forearm
tricep reflexes
extension of forearm
Brachioradialis reflexes
flexion and supination of forearm
Patellar or Quadriceps reflex
extension of lower leg
Achilles reflex
foot plantar against hand
Superficial (Cutaneous) Reflex
Plantar/Babinski Reflex
- plantar flexion of toes and inversion/flexion of forefoot (toes should curl for adults but fan for infants)
Interpret response
“positive or negative Babinski”
Cranial Nerves 3, 4, 6
Oculomotor
Trochlear
Abducens
Motor
- Assess extraocular movements (EOMs) by cardinal positions of gaze
*Results: Expect parallel tracking with no nystagmus.
*Nystagmus – disease of vestibular system, cerebellum, or brainstem
Cranial nerves IX and X:
Glossopharyngeal and Vagus Nerves
Motor and Sensory
Motor function
-Clarity of speech, ability to swallow, and note pharyngeal movement as person says “ahhh”; uvula and soft palate should rise in midline
-(NOT DOING) Verbalize - touch posterior pharyngeal wall with tongue blade, and note gag reflex
Sensory Function
-(NOT DOING) Verbalize - sense of taste posterior third of tongue
-Abnormal: Stroke, risk for aspiration
what are the 12 cranial nerves (number and name)
I. olfactory
II. optic
III. occulomotor
IV. trochlear
V. trigeminal
VI. abducens
VII. facial
VIII. acoustic
IX. glossopharyngeal
X. vagus
XI. spinal accessory
XII. hypoglossal
Negative Romberg test
pt has normal balance and posture
Positive Romberg test
pt had loss of balance/posture
what is the expected response seen with the triceps reflex
extension of forearm
infants/children and mental status
emotional and cognitive functions develop over time
aging adults and mental status
no decrease in general knowledge/vocab; response time may be slower; recent memory decreased by remote memory not; some sensory loss
what is the Four Unrelated Words test and why is it used?
tests a pt’s ability to lay down new memories; highly sensitive and valid memory test; used for alzheimer dementia pts, anxiety pts, and depression
risk factors for suicide and how to determine if a pt is serious
previous risk; giving away valuables; risk of hurting themselves; feelings of hopelessness, despair, etc.
why would a mini-status exam be used?
screens for cognitive function only and detects organic disease; useful for initial and serial measurement of cognition over time
what are organic diseases
mental diseases that develop over time instead of a psychiatric illness; delirium, dementia, Alzheimer’s, intoxication, withdrawl
psychiatric illness
anxiety, Schizophrenia, manic depression, OCD
- With increasing age, there is no decrease in general knowledge but people have a slower response time, recent memory is decreased, remote memory is usually not affected. There may also be some vision and hearing impairments that can affect socialization and memory.
The nurse is administering a Mini-Cog test to an older adult woman. When asked to draw a clock showing the time of 10:, the patient drew a clock with the numbers out of order nd with an incorrect time. This result indicates which finding?
a. Cognitive Impairment
b. Amnesia
c. Delirium
d. Attention-deficit disorder
a. Cognitive Impairment
what are the normal milestones for children
hold head up, roll over, sat alone, walked alone, first tooth, first words, first sentence, potty trained, ties shoes, dressed without help
when testing various parts of the nervous system, would a negative response be considered normal or abnormal?
normal
what does decorticate rigidity/posturing indicate
hemispheric lesion of cerebral cortex
what does decerebrate rigidity or posturing indicate
lesions in brainstem or upper pons
which is more life threatening, decorticate rigidity or decerebrate rigidity?
decerebrate rigidity
what is different about the vagus nerve
it goes down your spine instead of just staying in the head and neck area
