IM1- Exam 3 Material Flashcards
Before you begin your head-to-toe assessment what are some things you should consider?
Age group
organization of the assessment
What is the single most important neuro assessment component?
LOC–> level of consciousness
Why is the level of consciousness one of the most important components of the neuro exam?
It is often the first clue of a deteriorating condition.
When we are testing LOC what are some of the things we are looking for?
Alert: attentive, follows commands, if asleep - wakes promptly and remains attentive
lethargic: Drowsy but awakens, slow to respond
obtunded: difficult to arouse, need constant stimulation
stuporous/semi-comatose: arouses only to vigorous/noxious stimuli
comatose: no response to verbal or noxious stimuli, no movement except deep tendon reflex.
When should you start looking/testing for LOC?
The moment you walk into the patients room.
True or false: there is special testing for observing a patients LOC
False
What is cognitive awareness?
Finding out if the patient is oriented to person,place, time and event
What is cognitive awareness also known as?
Mentation
What questions can we ask to test a patient cognitive awareness?
- What is your name and DOB?
- Where are you right now?
-What year/day is it? - What has brought you to the hospital?
When asking a patient their name and date of birth you are testing that they are oriented to what?
Person
When asking a patient where they are you are testing that they are oriented to what?
Place
When asking a patient what year/day it is you are testing that they are oriented to what?
Time
Why is asking a patient what day it is not as effective as asking what year when testing their cognitive awareness?
Often times when a patient is in the hospital an extended period of time patients become confused.
When testing Cranial nerves III, IV and VI what are we testing for?
Pupil response and cardinal gaze
When we are assessing pupil responses what are things we are assessing
size and shape of pupils and compare to scale
How do we do our pen light exam when assessing pupil response?
1.Start at ear with penlight and move in toward nose
2. Note change in size and speed and reaction
3. With penlight off, move penlight close to and away from pupils
How do we do our pen light exam when assessing the cardinal gaze
- use tip of unlit penlight
- have patient follow with eyes only
- about 9-12” from face, move the end of penlight in an H motion
How can we test cranial nerve VII?
Ask the patient to smile and show teeth
Ask patient to wrinkle forehead or raise eyebrows
What could be the reason a patient is unable to wrinkle their forehead or raise there eyebrows
They have had botox
What could you detect when asking a patient to smile showing teeth?
Facial Droop
How can we have a patient test cranial nerve XII?
-Ask patient to touch the roof of mouth with tongue
- protrude tongue out of mouth
- move tongue side to side
How can we test cranial nerve Xl?
-Place hands lightly on patient shoulder
-Ask the patient to shrug shoulders
Remember– you do not need to put all your weight down just enough to have a small amount of resistance.
True or False: Testing motor function is part of both the neuro and musculoskeletal assessments?
True- Remember we will complete the motor function as part of our neuro exam
What are ways we test a patients motor function?
- hand grasp & toe wiggle (HGTW)
- Flexion and extension w/resistance