Neuro Assessment Flashcards
The evaluation of the health status of a client with a neurologic disorder or dysfunction
Neurological System Assessment
To obtain a _______ on the client’s neurological status abilities.
2. To _____, ___, and _____ data obtained in the nursing history.
3. To obtain data that will help _______ and plan of care.
4. To evaluate the ________ of health care and thus the progress of a client’s health.
5. To make ________about a client’s health status.
6. To identify areas for ______ and _____
To obtain a baseline data on the client’s neurological status abilities.
2. To supplement, confirm, or refute data obtained in the nursing history.
3. To obtain data that will help establish nursing diagnoses and plan of care.
4. To evaluate the physiologic outcomes of health care and thus the progress of a client’s health.
5. To make clinical judgments about a client’s health status.
6. To identify areas for health promotion and disease prevention.
what are the equipments used in neuro assessment
Clue: ENTSPTT COPOSSR
Examination gloves
Newspaper
Tape Measure
Snellen Chart
Penlight
Tuning Fork
Tongue depressor
Cotton-tipped applicators
Ophthalmoscope
Paper clip
Objects to feel
Sterile cotton ball
Substances to smell
Reflex hammer
Prior to performing the Neuro assessment Procedure, what should be done first and arrange in order
(Provide Client Privacy, Explain/ Discuss to client procedure, Introduce self, Perform Hand Hygiene, ask Client identity)
- Introduce Self
- Ask client Identity
3.Explain/Discuss to client procedure
4.Perform Hand hygiene and other prevention protocol - Provide Client Privacy
2 Types of Assessing the Neurological System
- Assess Level of Consciousness and Orientation
- Assess CNs (Cranial Nerves)
Type of Assessing Neuro System
“by asking client to identify name, location, day of the week, and year, note behavior and appearance.”
Assessing LOC and Orientation
Rationale for assessing Loc and Orientation
To determine spontaneity of responses to questions
For all assessments of the cranial nerves, have client ____ in a comfortable position at your ___ level.
sit, eye level
What are the 12 Cranial Nerves
Olfactory, Optic Oculomotor, Trochlear, Abducens, Trigeminal, Facial, Acoustic/Vestibulocochlear, Glossopharyngeal, Vagus, Spinal Accessory, Hypoglossal
What CNs Assessment and fill out the blank
To identify the ___ or ____ of the sense of smell
Olfactory (I)
absence & presence
In Assessing Optic (II), what is used to assess the DISTANT VISION
Snellen Chart
In assessing the visual fields in Optic, what should u do
Confrontation
what should the Client Read during optic Assessment
Newspaper or Magazine
Rationale for Optic (II)
To measure central (convergence) and peripheral vision
In Oculomotor (III)/Trochlear (IV)/Abducens (VI)
A. Inspect margins of the ____
B. Assess ____ movements
C. Assess ______ response to light and ____ in both eyes
A. Inspect margins of the eyelids
B. Assess Extraocular Movements
C.Assess pupillary response to light and accommodation in both eyes
Rationale for
Oculomotor (III)/Trochlear (IV)/Abducens (VI)
A. Inspect margins of eyelid
B. Assess extraocular movements
To determine parallel eye movement
Two Test Function for Trigeminal (V)
Test Motor Function
Test Sensory Function
In Trigeminal (V), what kind of Test Function and fill out the blank
ask client to clench teeth while you ___ the —- and ___ muscles for contraction
Test Motor Function
ask client to clench teeth while you palpate the temporal and masseter muscles for contraction
in Trigeminal (V), Rationale for test motor Function
To determine_____ of muscles
To determine bilateral contraction of muscles
What Equipment is used for Test Sensory Function in Assessing the Trigeminal Cranial Nerve?
Paper Clip
What Cranial Nerve Assessment is this?
Ask client to smile, frown, wrinkle forehead, show teeth, puff out cheeks, purse lips, raise eyebrows, and close eyes tightly against resistance
Facial (VII)
What is the Rationale of the test sensory function of the Trigeminal Cranial Nerve Assessment
- To determine ___ of the trigeminal nerve and ___ tract*
To determine lesions of the trigeminal nerve and spinothalamic tract
Rationale for Facial (VII) Cranial Nerve Assessment
To determine for ___ facial movement and central —- on the upper ____ neurons
To determine for symmetric facial movement and central lesionon the upper motor neurons
3 Kinds of test for Acoustic/Vestibulocochlear (VIII)
A. Testhearingability
B. PerformWebertest
C. Perform Rinne test
Rationale for Acoustic/Vestibulocochlear (VIII)
To determine g___ H___ A____
To determine gross hearing acuity
What kind of Cranial Nerve Assessment and Fill out the Blank
A. Test ___ function: ask
client to open mouth wide and say “ah” while using ____ on client’s tongue
B. Test ___ reflex
C. Check ability to ____
Glossopharyngeal (IX), Vagus (X)
A. Test motor function: ask
client to open mouth wide and say “ah” while using tongue depressor on client’s tongue
B. Test gag reflex
C. Check ability to swallow
Rationale for Acoustic/Vestibulocochlear
To check for presence of protective reflexes such as -, -, or -
To check for presence of protective reflexes such as gagging, coughing, or swallowing
What kind of Cranial Nerve Assessment and fill out blank
A. _____ against resistance
B.______ against resistance
Spinal Accesory (XI)
A. Shrug shoulders against resistance
B. Turn the head against resistance
Rationale for Spinal Accessory (XI) Cranial Nerve Assessment
Clue: (fill out blank) To check for ___ and ____ of contractions of ___ and ___ muscle
To check for smoothness and strength of contractions of sternocleidomastoid and trapezius muscle
What Cranial Nerve is this? And fill out the blank
Ask the client to ___ tongue, move it to side against resistance of a ____ and then put it back in the mouth
Hypoglossal XII
Ask the client to protrude tongue, move it to side against resistance of a tongue depressor, and then put it back in the mouth
Equipment used for Hypoglossal (XII) Assessment
Tongue Depressor
Rationale for Hypoglossal (XII)
To assess the ____ and ___ of the tongue
To assess the strength and mobility of the tongue
In assessing the extremities for sensation a nurse must perform all sensory testing with
client’s eyes _______ so he/she is unable to see when or where the stimulus strikes the skin. It is done through: _____, ______, ______
closed
Pain, light touch, sensitivity to position
a. Pain: Use the blunt and sharp
ends of a ______ or _______ to
skin surface. Apply in symmetrical
areas of extremities.
safety pin
paper clip
b. Light touch: use a wisp of _______ to different points along a surface of skin in symmetrical areas of extremities.
cotton
___________: Ask client to close both eyes. Then grasp finger or toe, holding it by its sides with your thumb and index finger. Move part alterately up and own. Ask client to tell you the direction it moved. Repeat with toes.
Sensitivity to position
How to test the motor and cerebellar function
Gait
Romberg’s test
Have a client walk across, tum and comeback (e.g. heel to toe, on their toes, on their heels)
Gait:
__________: have a client stand with feet together, arms at sides, both eyes open and eyes closed (for 20 - 30 sec). Protect client’s safety by standing at the side; observed for swaying.
b. Romberg’s test
In Assessing Deep tendon Reflex, what is the first step you should do?
A. Introduce Self
B. Provide Privacy
C. Obtain Equipment Needed
D. Explain each test to your patient
C. Obtain Equipment Needed
In assessing the superficial reflex of the Abdomen, patient must lie on the bed in________ position and legs should be ________ at the knees.
supine
slightly flexed
In abdominal superficial reflex assessment, Normally the umbilicus will _______ and toward the area being touched. If your patient has an upper or lower _______, his abdominal reflex may be absent.
move up
neuron disturbance
In Assessing Deep Tendon Reflex WHY should you explain each test to your patient and WHY should you encourage him to relax each part of his body as you test it?
For a Valid Finding , this include a Relaxed Patient
proper use of reflex hammer, proper positioning of the extremity and a relaxed patient.
DO NOT FORGET THE RELAXED PATIENT
During the abdominal superficial reflex assessment, it is expected that the umbilicus will move _____
Down
During the plantar reflex assessment, If everything is okay, his toes will curl ________.
downward
Dorsiflexion of the _______ and fanning of the other toes (Babinski sign) is an abnormal response.
great toe
If your patient is male, you will need to test the _______
Gently draw the stick down the upper portion of his right ______ thigh.
cremasteric reflex.
inner
Expect cremasteric muscle to ______ and the right testicle to _______ slightly.
contract
rise
what are the five reflexes in assessing the Deep Tendon Reflex
Bicep Reflex
Tricep Reflex
Brachioradialis Reflex
Patellar Reflex
Achilles Tendon Reflex
Absence of cremasteric reflex may be present in upper and lower motor _______
neuron disturbance.
In Corneal reflex It is tested carefully
using a clean wisp of ______. Lightly touch the outer corner of each eye on the ______.
cotton
sclera
In Assessing your patient’s deep tendon reflexes: Biceps Reflex
Why should you Slightly flex pt’s right elbow?
To allow it to swing freely
Condition such as _______ or ______ might result in loss of corneal reflex, either unilaterally or bilaterally
CVA
coma
What Equipment is used when assessing the deep tendon reflex?
Reflex Hammer
e.__________
This is elicited by gently touching the back of the pharynx with a cotton-tipped applicator
Gag or Swallowing Reflex
For the Bicep Reflex
- Then, with your ____ pressed
____ against his biceps muscle
tendon, hold your patient’s ___. - Keeping the reflex hammer held
____ between your ___ and
___, strike your ____. - Repeat the test on your
patient’s left bicep
- Then, with your thumb pressed
firmly against his biceps muscle
tendon, hold your patient’s elbow. - Keeping the reflex hammer held
loosely between your thumb and
fingers , strike your thumb - Repeat the test on your
patient’s left bicep
During gag reflex, a positive response is an equal elevation of the ______ and “gag” with _______.
Absent response on one or both side can be seen following a CVA and requires careful evaluation
uvula
stimulation
In assessing the Bicep Reflex, what rationale is for this?
Then, with your thumb pressed
firmly against his biceps muscle
tendon, hold your patient’s elbow.
Keeping the reflex hammer held
loosely between your thumb and
fingers, strike your thumb.
Repeat the test on your
patient’
s left bicep
Expect your patient’s biceps
muscle to contract, flexing his
arms at the elbow
For Tricep Reflex,
To do this, have pt __ his arm
at the elbow.
Then, hold his arm at the wrist.
With the reflex hammer, strike
the triceps tendon ___ over
his elbow.
Repeat the test on the other
elbow.
To do this, have pt flex his arm at the elbow.
Then, hold his arm at the wrist.
With the reflex hammer, strike
the triceps tendon directly over
his elbow.
Repeat the test on the other
elbow.
Choose the Correct Letter
A. Flexing or B. Extending
In Bicep Reflex, Expect your patient’s Biceps muscle to contract, ___ his arms at the elbow
In Tricep Reflex, Expect your patient’s Triceps muscle to contract, ___ his arms at the elbow
In Bicep Reflex, Expect your patient’s Biceps muscle to contract, FLEXING his arms at the elbow
In Tricep Reflex, Expect your patient’s Triceps muscle to contract, EXTENDING his arms at the elbow
In Brachioradialis Reflex
- Have pt ___ his forearm on his ___. His palm
should be facing ____.
rest, lap, down
when assessing the brachioeadialis, when striking the radius, should the palm turn upward or downward?
upward
the radius is located ____ the wrist
1”-2” above the wrist
In Patellar Reflex, what should you expect to see to the knee when striking the patellar tendon?
Knee Extension, his knee to swing forward
In the Patellar Reflex, where is the Patellar tendon Located?
Below or Above the Patella?
Below the Patella
In Achilles Tendon Reflex, if the Relaxation period is slowed, what should you suspect?
Hypothyroidism
In achilles Tendon Reflex, Hold your patient’s Right foot with you__ (left or right) hand
Gently Rotate his foot ___ (outward or inward)
Left, Outward
When Striking the Achilless Tendon, what flexion should you watch on his ankle?
What should you Observe after the contraction?
Plantar Flexion,
Obserbe quickly the Muscle relaxes after contraction
