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N321: Nursing Assessment of Clients > Module 11 - Neurological System Portion > Flashcards

Module 11 - Neurological System Portion Flashcards

1
Q

The nervous system is like the ___ of the body

A

Switchboard operator of the body (it processes, filters, and automatically/voluntarily routes messages)

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2
Q

3 Major Functioning Units of the Nervous System

A
  1. Spinal Cord Level
  2. Brain Stem and Subcortical Level
  3. Cortical Level
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3
Q

What is the spinal cord level

A

the lowest functional level of NS

controls automatic motor responses (reflexes)

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4
Q

What is the brain stem and subcortical level

A

controls BP, respiration, equilibrium, and primitive emotions

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5
Q

What is the cortical level

A

Responsible for cognition

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6
Q

Central nervous system

A

brain and spinal cord

network of coordination and control of the body

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7
Q

Peripheral nervous system

A

cranial nerves, spinal nerves, ANS (SNS+PNS)

motor and sensory nerves and ganglia outside the CNS which carries information to and from the CNS

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8
Q

How many pairs of cranial nerves are there

A

12

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9
Q

How many pairs of spinal nerves are there

A

31

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10
Q

Spinal nerves are ___ nerves

A

somatic (they innervate voluntary muscles)

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11
Q

Why do we avoid palpating or taking carotid pulse in non-emergency situations?

A

to not trigger baroreceptors in the brain

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12
Q

How much blood supply does the brain get

A

15 to 20% of the total cardiac output goes to the brain

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13
Q

What brings blood to the brain

A

The Basilar Artery

It is made from the 2 internal carotid arteries and 2 vertebral arteries joining together

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14
Q

3 Major Units of the Brain

A

Cerebrum

Cerebellum

Brainstem

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15
Q

Cerebrum

A

2 Hemispheres divided into lobes

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16
Q

Gray Matter of the Cerebrum

A

Outer layer (of the cerebral cortex)

made up of cell bodies

Controls higher mental function, general movement, visceral functions, perception, behavior, and integrates these functions

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17
Q

White Matter of the Cerebrum

A

Nerve fibers and myelin (heavily myelinated)

Bulk of it is in the inside of the cerebrum

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18
Q

Disorders associated with White Matter

A

Multiple Sclerosis

CMV

Encephalitis

Folate or Vit-B12 Deficiency

Vasculitis

PKU (Phenylketoneuria)

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19
Q

Frontal Lobe

A

Lobe of cerebrum

Responsible as a motor cortex, and for voluntary skeletal movement and fine repetitive motor movements and eye movements

Has impact on intellect and emotion and higher order processing

Brocas Area and Motor Cortex in this lobe

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20
Q

Parietal Lobe

A

Lobe of cerebrum for processing sensory data

Assists in interpretation of tactile, visual, olfactory, gustatory, and auditory sensations; recognition of body parts and position; and acts as a communicator between sensory and motor areas of the brain

Somatosensory cortex here

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21
Q

Occipital Lobe

A

Primary vision center lobe of the cerebrum

provides interpretation of visual data and gives the ability to read and understand

Visual cortex here

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22
Q

Temporal lobe

A

Perception and interpretation of sounds along with determination of source, integration of taste/smell/balance/reception/interpretation of speech

Wernickes Area and Auditory cortex here

Works with the cerebellum to control balance

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23
Q

Broca’s Area

A

Area of frontal lobe responsible as the motor area of speech

If broca’s aphasia occurs here they cannot speak correctly

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24
Q

Wernicke’s Area

A

Area of the temporal lobe responsible for reception and comprehension of language/speech

If there is damage here the person can speak, but speaks nonsensically

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25
Q

Cerebellum

A
  1. Works with motor cortex for integration of voluntary movement
  2. processes sensory info from eyes, ears, touch receptors
  3. Works with vestibular system for reflexive control of muscle tone, equilibrium, and posture to produce steady and precise movements (BALANCE)
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26
Q

The cerebellums main functions are ___ and ___

A

balance and coordination

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27
Q

Potential Causes of Cerebellum Disorders and Symptoms?

A

Causes: Congenital issues, hereditary ataxia, acquired conditions

Symptoms: vary but typically include ataxia

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28
Q

Ataxia

A

impaired muscle coordination

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29
Q

Brainstem

A

pathway between spine and brain

controls many involuntary movements (like cardiac and resp)

Nuclei here have 12 cranial nerves

Has a reticular formation running through it, and is mostly made of 3 main parts

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30
Q

3 Main Parts of the Brainstem

A

Midbrain

Pons

Medulla Oblongata

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31
Q

What does the reticular formation do

A

Contains a network of fibers for muscle stimulation

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32
Q

Main functions of the brainstem

A

Counteract gravitational forces

Regulate cardiac and resp systems

Maintain consciousness

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33
Q

Medulla Oblongata

A

Contains CN IX -XII

Controls respiration, circulation, vasomotor activities, houses the respiratory center.

Controls reflexes like: swallowing, coughing, vomiting, sneezing, hiccupping

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34
Q

Pons

A

Contains CN V-VIII

Regulates respiration, houses a portion of the respiratory center, controls voluntary muscle action

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35
Q

Midbrain

A

Contains CN III and IV

Reflex center for eye and head movement

Auditory Relay pathway

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36
Q

Diencephalon

A

Includes the hypothalamus, thalamus, and pituitary glands

Contains CN I and II

It relays info between the cerebrum, cerebellum, pons, and medulla (all sensory impulses except olfactory)

Also responsible for consciousness, perception of sensation, and abstract feelings

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37
Q

What sense does the thalamus/Diencephalon NOT relay?

A

Olfactory (scent)

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38
Q

Purpose of the Thalamus

A

perception of pain

temperature control

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39
Q

Purpose of Epithalamus

A

A pineal body for sexual development and behavior

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40
Q

Purpose of Hypothalamus

A

Major processing center of stimuli for the ANS

Maintains TEMPERATURE control, H2O metabolism, body fluid osmolarity, feeding behavior, neuroendocrine activity

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41
Q

Purpose of Pituitary Gland

A

HORMONAL GROWTH CONTROL

lactation

VASOCONCSTRICTION

metabolism

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42
Q

Severe Brainstem injuries can lead to …

A

Decerebrate and Decorticate Posturing

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43
Q

Decerebrate Posture

A

arms and legs extended

toes pointed downward

head and neck arched backwards

muscles rigid

Usually indicates severe brainstem damage

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44
Q

Decorticate Posture

A

arms flexed

clenched fists

extended legs held straight out

Arms bent inward toward the body with wrists and fingers bent and held to chest

muscles rigid

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45
Q

What is more ominous, decerebrate or decorticate posturing?

A

Both are dangerous, but Decerebrate is more ominous (since its association with brainstem injury)

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46
Q

Spinal Cord Length

A

40 to 50 cm

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47
Q

What constitutes the spinal cord?

A

Fibers grouped into 2 tracts that run carrying sensory (afferent), motor (efferent), and automatic impulses between brain and body

there are 31 spinal nerves covered in myelinated white matter making ascending and descending tracts with gray matter nerve cell bodies

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48
Q

How are the gray matter cell bodies organized in the spinal cord?

A

In a butterfly shape for the anterior and posterior horns

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49
Q

Ascending Tract

A

carries SENSORY (Afferent) data to the brain

mediates and facilitates sensation like complex discrimination to touch, pressure, vibration, joint positions, and two point discrimination

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50
Q

Descending Tract

A

Carries MOTOR (Efferent) impulses from the brain to the body

Impulses conveyed to various muscle groups by inhibiting or exciting spinal activity

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51
Q

Sympathetic System is ___ or ___

A

Fight or Flight

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52
Q

Parasympathetic System is ___,___,___

A

Feed breed rest

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53
Q

ANS

A

Autonomic NS which controls body functions not directly monitored

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54
Q

Somatic NS

A

Deliberate actions / voluntary muscle movement

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55
Q

CN I

A

Olfactory Nerve

Sense of Smell

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56
Q

CN II

A

Optic Nerve (NOT Peripheral NS!)

Vision

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57
Q

CN III

A

Oculomotor Nerve

Upward, downward, medial eye movement, lid elevation, pupil constriction

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58
Q

CN IV

A

Trochlear Nerve

Eye movements downward and medial

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59
Q

CN V

A

Trigeminal Nerve

Somatic Sensation of face, mouth, cornea

Muscles of Mastication

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60
Q

CN VI

A

Abducens Nerve

Eye movements laterally

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61
Q

CN VII

A

Facial Nerve

Controls facial expression muscles and anterior taste of tongue

Salivation, scalp, facial movement, lacrimation

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62
Q

CN VIII

A

Acoustic Nerve

Cochlear hearing (and balance)

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63
Q

CN IX

A

Glosso-pharyngeal nerve

External ear, taste posterior 1/3, carotid reflexes, sinus, baro and chemoreceptors

Gag reflex, swallow reflex, salivation

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64
Q

CN X

A

Vagus Nerve

external ear, pharynx, swallow, pronation, bronchoconstriction, gastric secretion, peristalsis

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65
Q

CN XI

A

Accessory Nerve

Swallow, pharyngeal muscles, head turn, shoulders rise

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66
Q

CN XII

A

Hypoglossal nerve

tongue movements

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67
Q

What type of nerve is CN I

A

S

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68
Q

What type of nerve is CN II

A

S

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69
Q

What type of nerve is CN III

A

M

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70
Q

What type of nerve is CN IV

A

M

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71
Q

What type of nerve is CN V

A

S and M

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72
Q

What type of nerve is CN VI

A

M

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73
Q

What type of nerve is CN VII

A

S and M

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74
Q

What type of nerve is CN VIII

A

S

75
Q

What type of nerve is CN IX

A

S and M

76
Q

What type of nerve is CN X

A

S and M

77
Q

What type of nerve is CN XI

A

M

78
Q

What type of nerve is CN XII

A

M

79
Q

The weber and rinne tests are important for which cranial nerve

A

CN VIII

80
Q

The 5 Sense are controlled by which Cranial Nerves

A

I - olfactory

II - Optic

III - Oculomotor

IV - Trochlear

VI - Abducens

All responsible for smell, vision, pupillary constriction, extraocular movement

81
Q

What cranial nerves control taste?

A

VII - Facial

IX - Glossopharyngeal

82
Q

What cranial nerve controls hearing?

A

VIII - Acoustic

83
Q

What cranial nerve controls sensory innervation to face, teeth, tongue, eyes?

A

V - Trigeminal

84
Q

What things does the neurologic assessment accomplish?

A
  1. Level of functioning, emotional, mental capacity, and functioning are determined
  2. Monitors/Detects changes and to assess nervous system dysfunctions
  3. Evaluates motor, sensory, autonomic, cognitive, and behavioral elements
85
Q

The most complex nursing assessment of the physical examination is the …

A

neurologic assessment

86
Q

Any abnormal neurologic symptoms should be assessed using …

A

COLDSPA

87
Q

during neurologic and musculoskeletal exams there is a stress on …

A

safety!

88
Q

Pertinent Symptoms and information that need further assessment in the neurologic health history?

A

Dizziness
Numbness and tingling
loss of feeling
changes in sensation
mood changes
surgeries
difficulty or changes in speech/swallowing
hearing
memory
balance and coordination
head, back, neck injuries and accidents
seizure history
headaches
syncope
drug and ETOH use
chemical exposures
changes in sleep schedules
activity level
medications
changes in ADLS

89
Q

Sequence of techniques in neurologic exam?

A

Inspection –> Palpation

Auscultation and Percussion not necessarily needed

90
Q

When performing a neurologic physical exam, it is important to go ___ and ___

A

cephalocaudally and bilaterally

91
Q

The neurologic exam does not look only at motor, but also ___

A

sensory

92
Q

What things should be looked for during inspection via general survey and approach for a neurologic exam?

A

General appearance - is it appropriate, gait, posture, awareness, manner of grooming and dress

Get patients perception of things

Are they comfortable

Allow older patients longer response times

93
Q

Patient Perceptions in the physical neurologic assessment is considered ___ data

A

objective

94
Q

Spastic Hemiparesis

A

Gait where affected leg is stiff and extended

foot drags and toes scrape

Affected arm is flexed and adducted with no swing

95
Q

Ataxia

A

uncoordinated uncontrolled falling occurs in gait

96
Q

Parkinsonian Gait

A

stooped, rigid, short shuffling steps with difficulty starting and stopping

97
Q

Glasgow Coma Scale

A

gold standard scale for Level of consciousness

has 4 levels but does not assess verbal response

98
Q

4 Levels of the Glasgow Coma Scale

A
  1. Awake and Alert - Follows commands
  2. Lethargic - drowsy/tap awake
  3. Stuporous - Shake or shout to wake
  4. comatose - does not respond to verbal cues or pain stimuli
99
Q

What aspects of mental status are important to look at during a neurologic examination?

A

Behavior/Mood/Affect

Emotional state

does their mood change

non verbal cues they give

speech characteristics

thought processes and cognitive function

assessment of orientation, attention, and memory

their use of language

100
Q

Orientation Status

A

Test of awareness of person, place, and time for a patient

EX: *individualize to the specific person

Person - what is your name? address? who is examiner?

Place - tell me where you are?

Time - what day, month, year, season, president, etc

101
Q

How should you go about assessing memory?

A

Put it into the general conversation, do not just quiz them usually

102
Q

Memory is part of ___ function

A

cerebral

103
Q

If recollection of past is easier than present what tests should be done?

A

Immediate Memory Tests:

  1. Repeat numbers backward and forward
  2. Recent Memory - Dietary recall
  3. Remote Memory - past occupations and birth place
104
Q

What is intellectual functioning?

A

Ability to define proverbs, learn a new item, perform computation, possess the ability to read, and have insight and judgment into situations

105
Q

What plays a large roll in intellectual functioning?

A

Age and Culture

106
Q

What is the Mini Mental Status Exam for Elders?

A

A judgment of mental status that assesses: (ORRAcL)

1.Orientation
2.Registration
3.Attention and Calculation
4.Recall
5..Language

107
Q

What can mental status changes indicate?

A

Early indications of change to neurological status which could be difficult or subtle to detect:

May begin slowly with forgetfulness, memory loss, inability to concentrate or process info quickly

Could rapidly proceed to unconsciousness

108
Q

Causes for Mental Status Changes?

A

Neurological Issues
Fluid and Electrolyte Imbalance
Hypoxia
Poor perfusion
Nutritional Deficiencies
Infections
Renal and Liver Disease
Hyper/Hypothermia
Trauma
Medications/Toxins
Drug/ETOH Abuse

109
Q

What is the order of information to go by when doing the neurologic exam?

A

Patient Perceptions > What you see > What family says is occurring

110
Q

Proprioception

A

Ability to maintain posture, balance, and coordination

Done via the posterior columns of the spinal cord carrying stimuli and fibers for touch and integrating with the cerebellum

111
Q

Functions of the Cerebellum

A

Works with vestibular sense to correct movement

Balance and coordination

Integrates muscle contractions for posture

112
Q

If some non-neuro condition can cause motor issues..

A

do not assume the problem is from an issue of cerebellar function

113
Q

Ways to Test Cerebellar Function

A

Finger to nose (helps display upper extremity movement)

Finger Nose and Finger Movements

Rapidly Alternative Movements: Thumb to 4 fingers as rapidly as possible, or slapping thighs with palms alternating with the back of hands (note speed and accuracy)

Heel to Shin Standing

Romberg Test

Tandem/Tip Toe Walking

114
Q

How to test somatic sensation function?

A
  1. Sensation (Dermatomes, Major Peripheral nerves, forehead, cheek, hand, foot)
  2. Light Touch (wisp of cotton on diff. areas)
  3. Pain and Temp (sharp, dull, hot, cold)
  4. Vibration (tuning fork on bone prominence - ask localization stop and start)

*** always check bilaterally

115
Q

Anesthesia

A

Lack of sensation

116
Q

Hyperthesia

A

Very sensitive

117
Q

Hypothesia

A

decreased sensation/ dull sensation

118
Q

Paresthesia

A

Tingling sensation

119
Q

Dermatomes

A

Sensory areas of the body where peripheral nerves are

It is a relationship between spinal nerves and skin sensation and each of the roots provides sensation to a predictable area of the skin (but there is a lot of overlap)

120
Q

With sensory function it is important to also check for ___ sensitivity and ___ discrimination

A

position sensitivity and tactile discrimination

121
Q

Stereognosis

A

Can they make out the form/what is in their hand when eyes are closed

122
Q

Graphesthesia

A

If you write something with your finger on their palm or back can they tell what you wrote

123
Q

Two Point Discrimination

A

What is the point that they can discriminate two different sensations

124
Q

Deep Tendon Reflexes (DTR)

A

Reflexes that reroute info to cause the movement from the spinal level while also sending info to the brain

125
Q

What are the main DTR?

A

Biceps
Brachioradialis
Achilles
Triceps
Patellar
Plantar

126
Q

How is DTR rated?

A

on a scale of 0 to 4 with +2 being normal

The strength is then also rated on 0 to 5 with 5 being normal strength

127
Q

Important Primitive Reflexes that should only be seen in newborns and infants

A

Sucking
Rooting
Moro (Startle)
Babinski
Blabellar
Palmar/Grasp
Plantar
Tonic Neck

128
Q

Rooting Reflex

A

baby will auto turn toward stimulus and make sucking/rooting motions when mouth or cheek is touched

129
Q

Sucking Reflex

A

when top of mouth is touched the baby will auto start sucking

130
Q

Moro reflex

A

Startle Reflex

In a response to sudden loss of support the baby will spread out their arms then pull them in and likely begin to cry

131
Q

Babinski Reflex

A

sole of foot being firmly stroked on an infant will cause the toes to fan out

132
Q

Glabellar Reflex

A

Tap patient on forehead, and if extinction does not occur and they continue to blink after a while that is an abnormal response

133
Q

Palmar/Grasp Reflex

A

put finger in babies hand, they should grasp around it

134
Q

Plantar Reflex

A

In adults, the stroking of the foot should cause this flexion inward of toes rather than a babinski response

135
Q

Tonic Neck

A

Fencing Reflex

When head is turned to one side, babies arm on ipsilateral side will extend while contralateral arm will bend at elbow

136
Q

Important Superficial reflexes

A

Abdominal
Anal
Corneal
Cremasteric

137
Q

Abdominal reflex

A

4 Strokes toward the umbilicus should elicit abdominal contraction

138
Q

Anal Reflex

A

Anal Wink

Reflexive anal contraction to stimulus to the skin around the anus

139
Q

Corneal Reflex

A

Reflexive blinking from stimulation of the cornea (by touch or foreign body)

Touch the cornea with cotton in a coma patient usually

140
Q

Cremasteric Reflex

A

Only in males

if inner thigh is stroked, the cremaster muscle will pull up on the ipsilateral testicle

141
Q

When a patient states they have headaches what should you analyze?

A

COLDSPA (pain)

Acute or chronic

localized or generalized

142
Q

90% of headaches are …

A

benign, caused by muscle contraction and or vascular issue (migraine or cluster)

143
Q

10% of headaches are…

A

a serious medical issue

144
Q

Dizziness

A

a “fainting sensation”

145
Q

Vertigo

A

Sensation that everything is “spinning”

can be accompanied with nausea, vomiting, nystagmus

146
Q

Syncope

A

temporary loss of consciousness

“black out” / “had a spell”

147
Q

Paresthesia

A

Numbness or tingling

148
Q

Symptoms of dizziness, vertigo, syncope, or paresthesia can be …

A

benign OR serious (like in an impending CVA) so investigate thoroughly

149
Q

Possible causes for dizziness, paresthesia, syncope, and vertigo?

A

diabetes

neurological issues

metabolic issues

cardiovascular issues

renal issues

inflammatory diseases

toxins

150
Q

Disorders of the CNS

A

Multiple Sclerosis

Generalized Seizure Disorder

Meningitis

Lyme Disease

Space occupying lesions

Cerebral palsy

Normal pressure hydrocephalus

Spina bifida

Amyotrophic lateral sclerosis

151
Q

Disorders of PNS (peripheral)

A

Myasthenia Gravis

Trigeminal neuralgia (tic douloureux)

Bells Palsy

Gullain barre Syndrome (GBS)

Peripheral Neuropathy

152
Q

Multiple Sclerosis

A

immune destruction of myelin sheathing

153
Q

Generalized Seizure Disorder

A

Systemic disease, head trauma, toxins, stroke, or hypoxic syndromes cause this

S/S: disturbances in consciousness, behavior, sensation, autonomic functioning, urinary and fecal incontinence

154
Q

Meningitis

A

Inflammation, bacterial or viral, of the fluid and membranes surrounding the brain and spinal cord (can cause stiff neck and headache)

Kernig and brudzinski signs indicate this

155
Q

Lyme Disease

A

caused by ticks

Has 3 Stages:

  1. bulls Eye rash
  2. Neuro and cardio symptoms (facial palsy, swollen knees, etc)
  3. Arthritis and worsening neuro s/s
156
Q

What can help cure lyme disease?

A

Antibiotics

157
Q

Space Occupying Lesion

A

Primary or metastatic

S/S depend on the location

158
Q

Cerebral palsy

A

non progressive issue with anoxia or hypoxia

permanent movement disorders starting in childhood

159
Q

Normal Pressure Hydrocephalus

A

Corrected by V-P Shunt

liquid gathering in skull/brain

160
Q

Spina Bifida

A

Neural tube defect (incomplete dev of brain, spinal cord, or protective coverings) causing spinal parts to come out of the back

161
Q

Amyotrophic Lateral Sclerosis

A

Form of muscular dystrophy

Weakness muscles and is progressive

ALS/Lou Gehrigs Disease

162
Q

CVA

A

Cerebrovascular Accident

Brain attack or stroke - sudden focal neurologic deficit resulting from impaired circulation to/within the brain

163
Q

Causes of CVA

A

associated with cario disease

thrombosis

embolism

hemorrhaging causing circulation impairment

164
Q

Most common site of CVA?

A

distribution of the anterior circulation of the brain

165
Q

Warning Signs of Stroke

A

Sudden weakness, numbness, facial/arms/leg paralysis (especially on one side)

Sudden vision trouble in one or both eyes, diplopia, monocular blindness

Sudden confusion, dysarthria, aphasia

Sudden severe headache without apparent reason

Sudden trouble walking, dizziness, loss of balance, or falling without reason, loss of coordination

166
Q

Dysarthria

A

difficulty speaking

167
Q

Aphasia

A

Difficulty understanding speech

168
Q

F.A.S.T

A

Acronym for stroke risk - stands for:

Face (have them smile, does one side droop)

Arms (raise both arms, is their drifting downward of one)

Speech (can they repeat simple phrase without strangeness or slurring)

Time (if you see a sign call 911 immediately)

169
Q

Parkinson’s Disease

A

Slowly progressing degenerative disorder of dopamine NTs in the brain resulting in poor communication in the neuronal system

170
Q

Causes of Parkinson’s Disease

A

questionable genetic links

environmental components

can be viral, vascular, or toxic in origin

171
Q

S/S of Parkinson’s Disease

A

Tremors at rest

fatigue

masked facial expression

parkinson’s shuffling gait / propulsive gait

muscle rigidity

“pill rolling” - like something is between their fingers

behavioral changes and dementia

commonly causes stiffness or slowing of movement

coordination, movement, and balance issues

172
Q

Alzheimer’s disease

A

destruction of brain cells progressively leading to decline in memory and mental functions

Insidious and Neurologic

173
Q

Most common cause of demetia is …

A

alzheimers disease

174
Q

What are causes for Alzheimer’s disease?

A

combo of genetics lifestyle, and environment alongside the major risk of increasing age

BUT this is not a normal aging process

175
Q

Alzheimer’s Onset?

A

Late more common than early onset

Early onset occurs between 30-60 with less than 10% of all alzheimers being early and usually due to genetics

176
Q

Myasthenia Gravis

A

Peripheral NS disorder

chronic, autoimmune disorder involving lower motor neurons and muscle fibers

Immune system attacks synaptic junctions between nerve and muscle fibers

177
Q

Tic Douloureux

A

Trigeminal Neuralgia

Damage to 5th cranial nerve (could even be from surgery) that is chronic and due to compression by a small artery that wears away CN V’s myelin

It may be associated with MS, tumors, AVM, injuries (sinus, oral, CVA, facial trauma)

PNS disorder

178
Q

Treatment for Tic Douyloureux

A

Meds, Injection, surgery

179
Q

Bells Palsy

A

Temporary facial paralysis from damage/trauma to facial nerve (CN VII) from swelling, inflammation, or compression

Could potentially be viral and can be treated with antibiotics or prednison

risk for aspiration and low self esteem is possible

TEMPORARY and can affect anyone (can recover in 2 weeks to several months)

PNS disorder

180
Q

GBS

A

Gullain barre syndrome (PNS disorder)

Autoimmune disorder that is an acute inflammatory demyelination of peripheral nerves

It is rapidly progressive and may be bacterial or vial in origin or links to immunizations or Epstein barr syndrome - We truly do not know the cause

Treatment is more supportive as it is progressive

181
Q

Peripheral Neuropathy

A

PNS issue

motor and sensory issues seen in hands and feet

caused by diabetes, toxins, vit b 12 deficiency, autoimmune issues, neurologic conditions

s/s: numbness, tingling, burning, cramping

182
Q

Depression

A

May accompany anxiety and has many causes

can affect all ages, races, genders

NEED TO ASSESS - asking will not cause a suicide attempt and they need assistance

BE ATTUNED TO THE POTENTIAL

183
Q

At risk populations for depression?

A

chronic disease patients

LGBTQ

“devastating” acute condition patients

184
Q

Neurologic Nursing Diagnoses

A

risk for injury

risk for activity intolerance / activity intolerance

ineffective airway clearance

anxiety

risk for aspiration

disturbed body image

imbalanced body temp

bowel incontinence

powerlessness

risk for infection

impaired verbal communication

caregiver role strain

unilateral neglect

impaired urinary elimination

impaired walking

wandering

compromised family coping

N321: Nursing Assessment of Clients (18 decks)

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