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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
how does overdose cause unconsciousness
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how does ureamia cause unconsciousness
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how does temperature cause unconsciousness
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how does infection cause unconsciousness
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how does psychogenic cause unconsciousness
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how does septicaemia cause unconsciouness
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how does surgery cause unconsciousness
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what r the types of skull facture
depression facture: skull push down to the brain compound facture: unstable, the bone may move around
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what r the types of primary head injury
34
what is craniofacial surgery
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
why measure consciousness, how is it measured
To assist management Potential prognosis Consciousness is commonly measured in terms of spontaneous activity and responsiveness to stimulation
36
assessment for consciousness
Comprises examination of: Health history Consciousness Mental status, Cognitive function and communication Cranial nerves Motor function Sensory function Deep tendon reflexes Vital signs
37
health history for consciousness assessment
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
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what r some subjective daqtaq in health history for consciousness assessment
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assessing consciousness
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
how is level of consciousness measured
Measured in terms of spontaneous activity and responsiveness to stimulation Distinguishes from behavioural states Common use of Glasgow Coma Score Measures BEST response
41
GCS
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
3 parameter of GCS
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
how to best assess
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
arousal
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
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Best verbal response
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
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Factors influencing Verbal response
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best motor response
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
pronator drift
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
painful stimuli
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
central stimuli
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)
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peripheral stmulus
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
Types of motor response to stimuli
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
Questions to ask yourself when assessing motor response
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
movement
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
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decorticate
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
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decerebrate (left side)
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
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factors affecting motor response
58
pupil rxn
If a pupil dilates this is a serious sign of raised intracranial pressure and is considered a medical emergency
59
Three components in the intracranial cavity contribute to ICP
Three components in the intracranial cavity contribute to ICP Cerebral tissue (80%) Blood –arterial & venous (10%) Cerebrospinalfluid (10%) Normal ICP less 15mmHg pressure
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Monro-Kellie Hypothesis
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
Causes if elevated ICP
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
signs and symptoms for elevated ICP
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
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resulr of elevated ICP
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
Cranial nerves
Vision (Optic: CNII) Light (Oculomotor CNIII) Cornea ( Trigeminal:CN V & Facial:VII) Airway (Gag & swallow)- Glossopharyngeal:CN IX & Vagus: CNX)
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changes to vital signs
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
assessment of pupil
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
pupil: size and rxn
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.
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pupil rxn
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
eye movement
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
cognitive function
Concentration Memory:Immediate, Recent, Long term Communication - Interpretation and recognition of speech - Comprehension of written word
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Sensory & Perceptual Function
Light touch Pain and temperature Vibration Tactile Position sense
72
Proprioception & cerebellar function
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)
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Language
Expressive (dominant hemisphere frontal lobe) - Difficulty with expression Receptive (temporal) Speech fluent but comprehension poor
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Issues for consideration for GCS
Assessment and clinical application accurate communication Subjective vs objective data Assessment of children over 5 vs under 5 Reliability of data
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paedetric GCS
Eyes as per adult scale Best motor response as per adult scale Verbal response changed
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Paediatric verbal response

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