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5084 > L2 neurological assessment > Flashcards

L2 neurological assessment Flashcards

1
Q

what r the protecting structures

A

Skull

Meninges

Protecting structures

Cerebro-spinal fluid

Arrangement of Blood supply

Blood-Brain Barrier

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2
Q

what r the cranial bones

A
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3
Q

what r the facial bone

A
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4
Q

layers of the brain

A
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5
Q

what is CSF,where is it produced at what rate

A

CSF is the fluid that flows through and protects the 4 ventricles of the brain, the subarachnoid spaces and the spinal cord.

Produced by choroid plexis in ventricles 21mls/hr

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6
Q

circle of willis - main blood supply to the brain

A

the arteries compose the circle of Willis are the 2 anterior cerebral arteries joined to each other by the anterior communicating cerebral artery and to the posterior cerebral arteries by the posterior communicating arteries.

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7
Q

what is neurological assessment for

A

Determine whether the patient has a neurological problem

Establish what impact the condition has on the patient’s independence and daily life

Baseline assessment

Determine changes

Detect life threatening situations

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8
Q

what is the goal of neurological assessment

A

To standardise clinical observations, always conduct a set of neurological observations with the oncoming nurse to minimise subjectivity

Monitor progress, a neuro patient often deteriorates slowly and an accurate neuro assessment can identify a deterioration very early

Provide a guide to estimate a patient’s prognosis

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9
Q

what is consciousness

A

It is an active process

Wakefulness or alertness must be present

Potential for self-awareness

Perceived sensation of internal and external stimuli

Memory can be used, recovered and displayed

Decision making capacity

Cognitive functioning

  • Consciousness is more than being awake. It is a complex and multifaceted condition that is present in health.
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10
Q

dbescrie consciousness as a continuum? what is its component

A

The reality is that consciousness can be located along a continuum between two extremes

Consciousness has 2 distinct components

Arousal
Awareness

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11
Q

what is arousal

A

The arousal component of wakefulness is dependent on the reticular activating system.

This system is found in the upper brainstem and diencephalon ascending the brainstem, through the thalamic region and to the cerebral cortex, with the thalamus acting as a ‘gate’ between both areas

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12
Q

what is awareness

A

Awareness relates to the capacity of the brain to select and direct

Sensation is the awareness that something is happening and perception is the appropriate processing of this information

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13
Q

what part of brain response for conciousness?

A

Prefrontal lobe primary centre for consciousness

Rest of activity at the subconscious level

Involves sensory input as well as motor output

Frontal lobes: Control and awareness (cognition)

Parietal, temporal and occipital lobes: Awareness,

Association areas: Making sense of stimuli

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14
Q

what is conciousness depend on?

A

Is dependent on oxygen and glucose supply

Auto regulation of blood flow: Effective in a wide range of blood pressures as well as the maintenance of an appropriate environment.

Metabolic regulation

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15
Q

what is cerebrl perfusion pressure

A

Mean Arterial Blood Pressure and Intracranial pressure

MAP- ICP = CPP

CPP less than 40mmHg leads to severe compromise of cerebral tissue

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16
Q

what os unconsciousness

A

A physiological and psychological state in which the patient is not responsive to sensory stimuli and lacks awareness of self and the environment

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17
Q

what cause impairment of consciousness? and what does it interfere

A

Injury, lesions or pressure occurring anywhere within the RAS can impair consciousness.

Interference with the electrical activity of the brain, brain metabolism or the neurotransmitters required for impulse transmission

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18
Q

what is the effect of altered consciousness?

A

Reduced or lost protective reflexes

Potential for harm if heightened consciousness

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19
Q

what is the mechanism of the cause of unconsciousness

A

The cells of the Reticular Activating system are sensitive to alterations in biochemistry and haemodynamic status therefore the causes of unconsciousness are varied and extend beyond structural cerebral lesions

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20
Q

what is the causes of unsciousness

A
  1. infective: meningitis, encephalitis
  2. neuplasia: gliomas (primary), metastatic cancer
  3. trauma: cerebral oedema
  4. haemorrhage: extradural, subdural, subarachnoid,intracerebral
  5. vascular: TIA (transient ischaemic attack), CVA
  6. hydrocephalus: increase ICP
  7. metabolic: hypoxic, hypercapnia, hypoglycemia, uraemia.
    - other causes: shock, drug overdose, anaesthetics, alcohol
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21
Q

shock cut to the causes of unconsciousness

A

AEIOU TIPS

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22
Q

how does alcohol cause unconsciousness

A
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23
Q

how does epilepsy cause unconsciousness

A
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24
Q

how does insulin cause unconsciousness

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25
Q

how does overdose cause unconsciousness

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26
Q

how does ureamia cause unconsciousness

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27
Q

how does temperature cause unconsciousness

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28
Q

how does infection cause unconsciousness

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29
Q

how does psychogenic cause unconsciousness

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30
Q

how does septicaemia cause unconsciouness

A
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31
Q

how does surgery cause unconsciousness

A
32
Q

what r the types of skull facture

A

depression facture: skull push down to the brain

compound facture: unstable, the bone may move around

33
Q

what r the types of primary head injury

A
34
Q

what is craniofacial surgery

A

is a surgical subspecialty of plastic surgery and oral and maxillofacial surgery that deals with congenital and acquired deformities of the head, skull, face, Neck, jaws and associated structures. Although craniofacial treatment often involves manipulation of bone, craniofacial surgery is not tissue-specific

35
Q

why measure consciousness, how is it measured

A

To assist management

Potential prognosis

Consciousness is commonly measured in terms of spontaneous activity and responsiveness to stimulation

36
Q

assessment for consciousness

A

Comprises examination of:

Health history
Consciousness
Mental status,

Cognitive function and communication

Cranial nerves
Motor function
Sensory function

Deep tendon reflexes

Vital signs

37
Q

health history for consciousness assessment

A

Most important part of the assessment

Listening ability important on the part of the

assessor

People often use words such as ‘weakness, numbness, fatigue, turns, faint, funny which need to be explored

Family or others (witnesses) may need to be asked to contribute

History should include present, past and family

If person complains of any symptom take an indepth history of the symptom

Duration, frequency, intensity, type, location, setting, aggravations, associated phenomena, alleviating factors and related concerns

38
Q

what r some subjective daqtaq in health history for consciousness assessment

A
39
Q

assessing consciousness

A

Progression of altered consciousness

Focal signs

Presence of chronic condition

Drugs-prescription and non-prescription

Previous alterations in consciousness

Illness or injury

Witness report

40
Q

how is level of consciousness measured

A

Measured in terms of spontaneous activity and responsiveness to stimulation

Distinguishes from behavioural states

Common use of Glasgow Coma Score
Measures BEST response

41
Q

GCS

A

Component of neurological assessment of adolescent and adult patients

Used in conjunction with measurement of other parameters of cerebral function

Found as part of other scales such as Revised Trauma Score (+cardiovascular and resp status)

TRISS (trauma and injury severity score)

Objective assessment of level of consciousness (LOC)

Uses standardised approach

Consistency in use essential Can be less than reliable if staff not trained to use the scale (Rowley & Fielding 1991)

Score can be used to measure and trend neurological dysfunction, and as a basis for decisions of clinical management

  • GCS 8 or less intubate and ICU
42
Q

3 parameter of GCS

A

Observe and describe patients patterns of behaviour in 3 important responses

best eye opening (score 1–4) for arousal and awareness

best verbal response (score 1–5) indicating level of orientation, and

best motor response (score 1–6) for whole brain function.

Highest possible score =15; lowest =3

43
Q

how to best assess

A

Approach from the best side of the patient and assess arousal – awareness first, then move on to level of orientation followed by motor responses where the brain as a whole is assessed e.g:

Eye opening

Verbal

Motor

44
Q

arousal

A

If patient does not open eyes to normal speech then use increasing stimulus with pain as the last resort

first:
Do not Shout
Tactile stimulation/touch

45
Q

Best verbal response

A

Oriented in person, place and time (5) indicates short and long term memory intact

Disoriented /Confused (4) is where there are incorrect responses

Inappropriate (3) is where words make no sense or at random

Incomprehensible (2) moans and groans, words not distinguishable

None (1)

Other : indicate if ETT, tracheostomy, aphasia

46
Q

Factors influencing Verbal response

A
47
Q

best motor response

A

Can the patient process instructions and respond by obeying commands?

Record best arm response

Allow no ambiguity: For example ask patient to lift their left arm off the bed or hold up their hand rather than asking “Squeeze my hands” which may elicit a reflex grip. If you do this always ask the patient to release their grip

If no response use noxious stimuli

48
Q

pronator drift

A

Some assessments include looking to see if downward or pronator drift of the arms is present. This is done by asking the patient to close their eyes and extend their arms with palms upward.

If their arms drift down or the palm on one side pronates it may signal a possible arm weakness.

49
Q

painful stimuli

A

Stimuli may be central or peripheral

Type used may vary between facilities

In central stimuli the brain responds

In peripheral stimuli a response is elicited from the spinal cord

Think if you need to use pain as the patient may be exhibiting spontaneous movement and localising spontaneously

50
Q

central stimuli

A

Trapezius squeeze using thumb and two fingers at angle where neck and shoulder meet (need defined neck). Exert gentle pinch of about 1.25cm for between 10 and 20 seconds

Supra orbital pressure (discouraged) Sternalrub (discouraged)

51
Q

peripheral stmulus

A

Stimulus applied to immobile arm or foot

Spinal reflexes respond with withdrawal reflex not accurate reflection of cerebral function

Used to indicate specific movements for each limb. Tests flexion and localising to pain

Pressure exerted on nail bed at side of finger or directly to nail bed

52
Q

Types of motor response to stimuli

A

Obeys verbal commands (6)

Localises to painful stimuli (5)

attempts to locate or remove stimulus

Withdraws P/S (4) moves limb away from p/s or flexes toward source

Abnormal flexion (3) : decorticate

Abnormal extension (2): decerebrate

None (1)

53
Q

Questions to ask yourself

when assessing motor

response

A

Abnormal movements indicate severe brain dysfunction therefore ask yourself is the movement:

Flexion orextension?
If flexion occurs is it abnormal or a

withdrawal from the stimuli?
Normal is usually a brisk response

54
Q

movement

A

Posturing:

Decorticate: upper limbs flex, lower extend

Decerebrate; upper limbs and lower limbs extend (deep bilateral cerebral hemispheres, brainstem)

Mixed: contralateral lesion more pronounced

Absence: central problem or peripheral nervous system

55
Q

decorticate

A

Abnormal flexion and adduction of arms with extension of legs

Occurs when the brain stem is not inhibited by the motor function of the cerebral cortex

56
Q

decerebrate (left side)

A

This patient is decorticate on the right and decerebrate on the left

Abnormal extension, adduction and internal rotation of upper limbs

Midbrain/pontine damage

Record highest response in such situation

57
Q

factors affecting motor response

A
58
Q

pupil rxn

A

If a pupil dilates this is a serious sign of raised intracranial pressure and is considered a medical emergency

59
Q

Three components in the intracranial cavity contribute to ICP

A

Three components in the intracranial cavity contribute to ICP

Cerebral tissue (80%)
Blood –arterial & venous (10%) Cerebrospinalfluid (10%)
Normal ICP less 15mmHg pressure

60
Q

Monro-Kellie Hypothesis

A

That an increase in any one of the three components must be compensated for by a decrease in one or more of the other two components to allow the total volume to be constant

61
Q

Causes if elevated ICP

A

Space occupying lesion: intracerebral haematoma, extracerebral haematoma, abscess, tumour

Cerebral oedema related to damage to cerebral tissue due to hypoxia, haemorrhage, contusion or inflammation, hypocarbia, hypotension.

Blocked pathways or altered CSF production/absorption leading to hydropcephalus

Increase in Cerebral Blood Flow in system

62
Q

signs and symptoms for elevated ICP

A

Decreased LOC

Headache, vomiting

Papilloedema

Cushing’s Triad (Early stages)
Bradycardia, systolic hypertension,

bradypnea

Pupil inequality and decreased reaction to light

Diminished brain stem reflexes, altered breathing patterns

Motor posturing

63
Q

resulr of elevated ICP

A

Compromised cerebral blood flow

Downward herniation of brain tissue resulting in compression of the vital centres in the brain stem that control heartbeat and respiration

64
Q

Cranial nerves

A

Vision (Optic: CNII)

Light (Oculomotor CNIII)

Cornea ( Trigeminal:CN V & Facial:VII)

Airway (Gag & swallow)- Glossopharyngeal:CN IX & Vagus: CNX)

65
Q

changes to vital signs

A

Because the brain stem and Vagus nerve (CN X) play an important role in vasomotor tone, conditions affecting these areas can cause vital signs to change.

ICP produces a specific set of changes known as Cushing’s triad. Present in herniation syndromes

  • Cushing’s triad is a late sign of increased ICP. Once this pattern of vital signs occurs, brain stem herniation is already in progress and it may be too late to reverse it. To detect increasing ICP before it reaches this point, be alert for earlier signs: a subtle change in LOC or pupils, for example.
66
Q

assessment of pupil

A

Can be affected by:

Injury to brain and/or cranial nerve, especially III (occulomotor nerve)

Eye injury, surgery, cataract, blindness

Periorbital oedema

Contact lenses

Drugs: e.g.
• Opiates constrict (miosis)
• Atropine dilates (mydriasis)

67
Q

pupil: size and rxn

A

Direct and consensual pupil reaction

Pupils normally 3-8mm, symmetrical and constrict to 2-6mm with direct light stimulation and consensually when opposite eye tested. (20% have slight inequality of size normally)

Large non reactive: anoxia, midbrain infarct.

Mydriatics cause dilated and non or sluggish reaction in affected eye.

Hypothermia, barbiturate intoxication, and cholinergics cause non reactive pupils.

68
Q

pupil rxn

A

In one sided complete optic nerve damage there is no reaction to light in either eye when affected side tested. Both pupils constrict when unaffected eye tested.

Early sign of herniation syndrome is reduced pupil reaction to light on the ipsilateral (side of the lesion) side

Patients with chronic lung disease or hypoxaemia may have large sluggish reactive pupils

Mid size non reactive pupils can be due to organophosphates, midbrain lesion

Small pupils may result from miotics, opiates, organophosphates

Pinpoint reactive pupils from pontine haemorrhage

69
Q

eye movement

A

Corneal reflex

Eye movement

  • Primary position of eyes is midpoint:
  • Conjugate : eyes move together or follow = intact brain stem
  • Disconjugate; eyes move in different directions indicates cranial nerves 3,4,6 affected
  • Deviation of eyes?
  • Ocular movements?
  • Spontaneous eye movements?
70
Q

cognitive function

A

Concentration

Memory:Immediate, Recent, Long term

Communication
- Interpretation and recognition of speech

  • Comprehension of written word
71
Q

Sensory & Perceptual Function

A

Light touch
Pain and temperature Vibration
Tactile
Position sense

72
Q

Proprioception & cerebellar function

A

Involves posture, balance, position sense and co-ordination which are controlled by cerebellum (balance and co-ordination), vestibular apparatus (balance & movement correction) and posterior columns of spinal cord (muscle and position sense)

73
Q

Language

A

Expressive (dominant hemisphere frontal lobe)

  • Difficulty with expression Receptive (temporal)

Speech fluent but comprehension poor

74
Q

Issues for consideration for GCS

A

Assessment and clinical application

accurate communication

Subjective vs objective data

Assessment of children over 5 vs under 5

Reliability of data

75
Q

paedetric GCS

A

Eyes as per adult scale

Best motor response as per adult scale

Verbal response changed

76
Q

Paediatric verbal response

A

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