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Module 4 (MedSurg 2) > Neuro Assessment > Flashcards

Neuro Assessment Flashcards

1
Q

What are you monitoring on a neuro assessment? (NII)

A

alert and oriented LOC x4 (person, place, time, situation and DOB)
Pupil Size 2-4 mm PERRL
speech
HGTW, flexion, and extension bilaterally upper and lower
Sensations (pain, temp, touch, pressure)

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2
Q

How will you assess pain type in a pt?

A

Say “What do you feel or is this sharp or dull?”
irregular pattern
pt closes their eyes

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3
Q

How will you assess temperature for a neuro assessment?

A

Alcohol swab (cold) and back of hand (hot)

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4
Q

Assessment of Nervous System
subjective data or patterns

A

Pain
Main thing to remember is these are SAID by the pt and need questions
Health perception and management (med, physical, history) even if you have to call the pharmacy
nutrition patterns
elimination patterns
activity-exercise
sleep-rest
cognitive perception
self-perception and concept
role-relationship
reproductive
coping-stress tolerance
values

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5
Q

Health Perception and Management Questions

A

1 -What are your usual daily activities?
2 -Do you use alcohol, tobacco, or recreational drugs?
3 -What safety practices do you perform in a car? On a motorcycle? On a bicycle?
4 -Do you have hypertension? If so, is it managed?
5 -Have you ever been hospitalized for a neurologic problem?
Medication, health, and physical history

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6
Q

Nutrition Questions

A

1 -Are you able to feed yourself?*
2 -Do you have any problems getting adequate nutrition because of chewing or swallowing difficulties, facial nerve paralysis, or poor muscle coordination?
3 -Give a 24-hour dietary recall.

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7
Q

Elimination Questions

A

1 -Do you have incontinence of your bowels or bladder?*
2 -Do you ever experience problems with urinary hesitancy, urgency, retention?*
3 -Do you postpone defecation?
4 -Do you take any medication to manage neurologic problems? If so, what?

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8
Q

Activity-Exercise Questions

A

1 -Describe any problems you experience with usual activities and exercise as a result of a neurologic problem.
2 -Do you have weakness or lack of coordination?
3 -Are you able to perform your personal hygiene needs independently?

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9
Q

Sleep-Rest Questions

A

1 -Describe your sleep pattern.
2 -When you have trouble sleeping, what do you do?
Where do you sleep

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10
Q

Cognitive-Perception Questions

A

1 -Have you noticed any changes in your memory?
Do you experience dizziness, heat or cold sensitivity, numbness, or tingling?
Do you have chronic pain?
Do you have any difficulty with verbal or written communication?
Have you noticed any changes in vision or hearing?

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11
Q

Self-concepts Questions

A

Emotions about self

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12
Q

Role-Relationship Questions

A

changes in roles from spouse, parent, or breadwinner

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13
Q

Reproductive Questions

A

dissatisfied
tension caused in relationship
counseling?

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14
Q

Coping-Stress Tolerance Questions

A

usual pattern**
adequate to meet stressors in life
needs are unmet in the support system

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15
Q

Value Questions

A

influence to care**

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16
Q

Assessment of Nervous System
Objective Data

A

Physical exam

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17
Q

Objective = Physical Exam

A

mental status (general/cerebral function of pt functioning)
cranial nerve functions
motor function
sensory function
reflexes

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18
Q

Nervous System Assessment follows what sequence

A

logical
higher level of functioning to lower levels
- constant comparison of findings

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19
Q

Mental Status and Speech

A

LOC
Appearance and behavior (LOC, motor, posture, hygiene, expressions)
Speech (normal, slurred)
Cog Function (Time, Place, Person, and situation = knowledge, insight, solving, and calculations)
Constructional ability (mood and affect)

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20
Q

A patient who has deficits in self-care as evidenced by poor grooming is more likely to have

A

other cognitive deficits.

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21
Q

What diseases might affect cognitive function and need to be noted?

A

retardation
hallucinations
delusions
dementia

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22
Q

What is the 1st sign of a decrease in central neurologic function?

A

chnage in LOC

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23
Q

LOC and orientation levels
Alert -

A

awake and responsive, follows the command

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24
Q

LOC and orientation levels
Lethargic -

A

sleepy but arousable, drowsy, delayed response, drift to sleep

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25
Q

LOC and orientation levels
Stuporous -

A

arousable with difficulty, requires vigorous stimulation to respond (sternal rub)

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26
Q

LOC and orientation levels
Comatose -

A

not arousable

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27
Q

Appearance and Behavior

A

appropriate behavior?
grooming?
change or normal ask family

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28
Q

Speech assess

A

fluent/fragmented
dysarthria
follow instructions

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29
Q

Dysarthria

A

difficulty articulating

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30
Q

Constructional ability

A

perform simple tasks with objects in appropriate way

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31
Q

Thought content

A

clarity and cohesiveness
- hallucinations or delusions

32
Q

Abstract Thinking

A

interpret a proverb

33
Q

Judgment

A

ask what would they do if stopped by police or burning a building

34
Q

Emotional status

A

feel about themselves and their future
signs of depression

35
Q

_________ is one of the most important criteria for neurologic assessment – tests may be unreliable if the patient has problems with it.

A

Memory

36
Q

Long-term (Remote) memory loss

A

Birthdate
school attended
hometown
maiden name of mom

37
Q

Recall or recent memory

A

accuracy of medical history, health care providers seen within the past few days, mode of transportation to the hospital

38
Q

Immediate or New Memory

A

test by giving two or three words and asking the client to repeat the words to make sure they were heard. After about 5 minutes you ask the client to repeat the words

39
Q

In the Glasgow coma scale, what is the best and worst scores?

A

best = 15 (alert and oriented with obedience)
worse = 3 (no response)

40
Q

Glasgow Coma Scale

A

Level of responsiveness
eval neuro status of head injury pt
= motor, verbal, and eye opening

41
Q

S/S of deterioration in LOC status

A

HA
Restless
irritability
unusually quiet
sluured
Posturing
PERRLA

42
Q

Motor Functioning in neuro is determined by

A

ROM (tone and strength)

43
Q

Neuro sensory function

A

pain
light touch
vibration
position
discrimination

44
Q

Muscle Tone for neuro

A

muscular resistance to passive stretching
ROM arm and leg
gait, balance and coordination
finger to nose

45
Q

Dorsiflexion

A

foot up with toe at pt

46
Q

Plantar flexion

A

toes down and away from head

47
Q

A nurse is taking care of a pt with a head injury, when will the nurse obtain most of the data about the pts mental status
a) Nursing health hx
b) While observing pt behavior
c)asking specific problem-solving questions
d) giving answers of the mental written exam

A

a) Nursing health hx

48
Q

Cerebrospinal Fluid Analysis by

A

info about CNS diseases
Lumbar puncture
sterile procedure

49
Q

Reasons for a CSF

A

to obtain spinal fluid for exam
to measure & relieve spinal fluid pressure
to determine presence or absence of blood
to detect spinal subarachnoid block
to administer antibiotics intrathecally in certaincases of infection

50
Q

CSF normal findings

A

clear
colorless
odorless
NO RBC
contain little protein

51
Q

Lumbar puncture contraindicated in

A

presence of InterCranial Pressure or infection at the site of puncture (risk of downward herniation with more brain damage due to fluid shift suddenly)

52
Q

After getting CSF, when should the sample be transferred to laboratory

A

immediately and given directly to them

53
Q

Lumbar Puncture

A

requires pt relaxed
sterile
not if ICP increases or infection at

54
Q

Before Lumbar Puncture

A

pt needs to void
temp sharp pain
side lying or seated position

55
Q

PostOp LP Care

A

bed rest in flat position for 4-8 hours
encourage fluid
HA meds - low CSF = spinal HA
monitor neuro signs every 15 mins
= meningitis

56
Q

What are signs of bacterial meningitis?

A

fever
stiff neck
photophobia

57
Q

Post-Op LP HA

A

mild to severe
few hours to days
severe when sitting of standing

58
Q

Post-Op LP HA caused by

A

leakage of CSF at the site escaping into tissues
- depletes CSF in the cranium and produces tension and stretching when upright

59
Q

Xrays detect

A

fx
bone erosion
calcifications
vascularity
non-invasive

60
Q

Cerebroangiogram

A

with or w/o dye
allergies check

61
Q

CT ids

A

tumor
infarction
hemorrhage
hydrocephalus
malformations

62
Q

CT nurse management

A

shellfish, iodine or dye allergy if using contrast
perfectly still = no mvmt

63
Q

MRI detects

A

strokes
MS
TUMORS
TRAUMA
HERNIATION
SEIZURES

64
Q

MRI nursing management

A

claustrophobia
no metal or pacemaker

65
Q

MRA lasts how long

A

30-90 mins
patency and adequacy of serebral circulation
w/ contrast

66
Q

PET Scan is used with pts who have

A

stroke
AD
seizures
PD
tumors

67
Q

PET scan Before pt needs

A

2 IV lines
no sedatives or tranquilizers
empty bladder before

68
Q

Myelogram

A

Xray of spinal cord and vertebral column
detect disc ruptures or tumor
contrast in subarachnoid

69
Q

EEG is used for pts with

A

seizures
sleep apnea

70
Q

EEG is

A

no electricity
watch and record brain waves during episodes

71
Q

EEG prep

A

increase seizure activity
sleep deprived
no tranq or stimulants for 24-48 hours
omit coffee, tea, chocolate, and cola drinks
MEALS okay to eat bc BG altered change brain waves
no metal
45-60 mins

72
Q

Electromyography

A

MS
needle electrodes into the muscle to record specific motor units
altered by peripheral neuropathy

73
Q

Electroneurography

A

stimulates peripheral nerves and record actions
on surface to stimulate

74
Q

Evoked Potentials used to dx

A

MS

75
Q

Ultrasound

A

bx
carotid atery duplex scan
transcranial doppler

76
Q

An unconscious male pt arrives on HC5 with a head injury caused by a motorcycle crash. Which order should the nurse question?
a) Xray of the swollen spine
b) prepare pt for LP
c) send for CT scan
d)perform neuro checks every 15 mins

A

b) prepare pt for LP

increase of ICF can cause hemorrhage to already high pressure pt

Module 4 (MedSurg 2) (36 decks)

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