Neuro Assessment Flashcards
What are you monitoring on a neuro assessment? (NII)
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)
How will you assess pain type in a pt?
Say “What do you feel or is this sharp or dull?”
irregular pattern
pt closes their eyes
How will you assess temperature for a neuro assessment?
Alcohol swab (cold) and back of hand (hot)
Assessment of Nervous System
subjective data or patterns
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
Health Perception and Management Questions
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
Nutrition Questions
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.
Elimination Questions
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?
Activity-Exercise Questions
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?
Sleep-Rest Questions
1 -Describe your sleep pattern.
2 -When you have trouble sleeping, what do you do?
Where do you sleep
Cognitive-Perception Questions
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?
Self-concepts Questions
Emotions about self
Role-Relationship Questions
changes in roles from spouse, parent, or breadwinner
Reproductive Questions
dissatisfied
tension caused in relationship
counseling?
Coping-Stress Tolerance Questions
usual pattern**
adequate to meet stressors in life
needs are unmet in the support system
Value Questions
influence to care**
Assessment of Nervous System
Objective Data
Physical exam
Objective = Physical Exam
mental status (general/cerebral function of pt functioning)
cranial nerve functions
motor function
sensory function
reflexes
Nervous System Assessment follows what sequence
logical
higher level of functioning to lower levels
- constant comparison of findings
Mental Status and Speech
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)
A patient who has deficits in self-care as evidenced by poor grooming is more likely to have
other cognitive deficits.
What diseases might affect cognitive function and need to be noted?
retardation
hallucinations
delusions
dementia
What is the 1st sign of a decrease in central neurologic function?
chnage in LOC
LOC and orientation levels
Alert -
awake and responsive, follows the command
LOC and orientation levels
Lethargic -
sleepy but arousable, drowsy, delayed response, drift to sleep
LOC and orientation levels
Stuporous -
arousable with difficulty, requires vigorous stimulation to respond (sternal rub)
LOC and orientation levels
Comatose -
not arousable
Appearance and Behavior
appropriate behavior?
grooming?
change or normal ask family
Speech assess
fluent/fragmented
dysarthria
follow instructions
Dysarthria
difficulty articulating
Constructional ability
perform simple tasks with objects in appropriate way
Thought content
clarity and cohesiveness
- hallucinations or delusions
Abstract Thinking
interpret a proverb
Judgment
ask what would they do if stopped by police or burning a building
Emotional status
feel about themselves and their future
signs of depression
_________ is one of the most important criteria for neurologic assessment – tests may be unreliable if the patient has problems with it.
Memory
Long-term (Remote) memory loss
Birthdate
school attended
hometown
maiden name of mom
Recall or recent memory
accuracy of medical history, health care providers seen within the past few days, mode of transportation to the hospital
Immediate or New Memory
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
In the Glasgow coma scale, what is the best and worst scores?
best = 15 (alert and oriented with obedience)
worse = 3 (no response)
Glasgow Coma Scale
Level of responsiveness
eval neuro status of head injury pt
= motor, verbal, and eye opening
S/S of deterioration in LOC status
HA
Restless
irritability
unusually quiet
sluured
Posturing
PERRLA
Motor Functioning in neuro is determined by
ROM (tone and strength)
Neuro sensory function
pain
light touch
vibration
position
discrimination
Muscle Tone for neuro
muscular resistance to passive stretching
ROM arm and leg
gait, balance and coordination
finger to nose
Dorsiflexion
foot up with toe at pt
Plantar flexion
toes down and away from head
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) Nursing health hx
Cerebrospinal Fluid Analysis by
info about CNS diseases
Lumbar puncture
sterile procedure
Reasons for a CSF
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
CSF normal findings
clear
colorless
odorless
NO RBC
contain little protein
Lumbar puncture contraindicated in
presence of InterCranial Pressure or infection at the site of puncture (risk of downward herniation with more brain damage due to fluid shift suddenly)
After getting CSF, when should the sample be transferred to laboratory
immediately and given directly to them
Lumbar Puncture
requires pt relaxed
sterile
not if ICP increases or infection at
Before Lumbar Puncture
pt needs to void
temp sharp pain
side lying or seated position
PostOp LP Care
bed rest in flat position for 4-8 hours
encourage fluid
HA meds - low CSF = spinal HA
monitor neuro signs every 15 mins
= meningitis
What are signs of bacterial meningitis?
fever
stiff neck
photophobia
Post-Op LP HA
mild to severe
few hours to days
severe when sitting of standing
Post-Op LP HA caused by
leakage of CSF at the site escaping into tissues
- depletes CSF in the cranium and produces tension and stretching when upright
Xrays detect
fx
bone erosion
calcifications
vascularity
non-invasive
Cerebroangiogram
with or w/o dye
allergies check
CT ids
tumor
infarction
hemorrhage
hydrocephalus
malformations
CT nurse management
shellfish, iodine or dye allergy if using contrast
perfectly still = no mvmt
MRI detects
strokes
MS
TUMORS
TRAUMA
HERNIATION
SEIZURES
MRI nursing management
claustrophobia
no metal or pacemaker
MRA lasts how long
30-90 mins
patency and adequacy of serebral circulation
w/ contrast
PET Scan is used with pts who have
stroke
AD
seizures
PD
tumors
PET scan Before pt needs
2 IV lines
no sedatives or tranquilizers
empty bladder before
Myelogram
Xray of spinal cord and vertebral column
detect disc ruptures or tumor
contrast in subarachnoid
EEG is used for pts with
seizures
sleep apnea
EEG is
no electricity
watch and record brain waves during episodes
EEG prep
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
Electromyography
MS
needle electrodes into the muscle to record specific motor units
altered by peripheral neuropathy
Electroneurography
stimulates peripheral nerves and record actions
on surface to stimulate
Evoked Potentials used to dx
MS
Ultrasound
bx
carotid atery duplex scan
transcranial doppler
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
b) prepare pt for LP
increase of ICF can cause hemorrhage to already high pressure pt
