Neuro Assessment Flashcards
RED FLAG symptoms
- headache
- n/v
- dizziness
- weakness
- numb/tingling
- loss of consciousness
- seizures
- tremors
Pt education on stroke prevention
- ABC
- LOC
- asymmetric findings
Stroke considerations
- confusion
- trouble speaking
- dizzy
- loss of balance
- trouble seeing
- severe headache
WARNING SIGN of stroke
sudden numbness or weakness in face, arm, leg
Stroke risk factors include
- hypertension
- smoking
- hyperlipidemia
- diabetes
Delirium
confusion, altered mental status from physical/mental illness
(withdrawal, UTI, location change)
Dementia
symptoms cause by brain disorder that causes memory loss
(Alzheimer’s)
Mental status exam components
- appearance & behavior
- speech & language
- mood
- thoughts & perceptions
- cognitive function
* mini mental status exam (MMSE)- 11-point exam
Alert
Awake, eye contact
Lethargic
sleepy, wakes up to voice immediately
Obtunded
nodding off continuously
Stuporous
wont wake, painful touch
Comatose
nonresponsive
orientation
person, place, time
Pressure speech
cant get words out fast enough
Aphasia speech
trouble getting words out
The neurological examination consists of
- mental status exam
- cranial nerve exam
- moto/coordination exam
- sensory exam
- reflex exam
Pasue and look at patient (general survey)
- posture
- behavior
- expression
- hygiene
Motor systems
- motor
- cerebellar
- vestibular
- sensory systems
you need motor, cerebellar, vestibular, and sensory systems for what?
coordination of muscle movements
Cerebellar tests
- rapid altering movements
- point to point movements
- gait
- stance
- pronator drift
Motor system grading strength
0: no movement
1: visible contraction
2: FROM w/ gravity eliminated
3. FROM against gravity
4. FROM against some resistance
5. FROM against full resistance
Deep tendon grading
0: no response
1+: somewhat diminished
2+: average, normal
3+: brisker than average
4+: very brisk, hyperactive
Sensory system
- pain, light touch (must feel on both sides)
- position sense & vibrations
- discriminative sensations
In a neuro exam you will test for
- rapid altering movements
- point to point movements
- gait
- stance
- strength
Basic Assessment
initial assessment w/ every pt
(baseline)
Basic + assessment
when you suspect a neuro change
OR
pt has history of nero diagnosis
OR
taking medication that alters neuro
Glasgow coma scale examines
LOC, orientation, push/pull, pupils
Glasgow coma scale documenting
follows commands, 5/5 strength upper and lower extremities bilaterally, PERRLA
Normal score on Glasgow Coma Scale
15
Bad score on Glasgow Coma Scale
3
Decorticate rigidity
pulling into core
flexed internally rotated
Hemiplegia
flaccid
externally rotated
Decerebrate rigidity
flexed
pronated extended
Rapid altering movement examples
- hand flips on thighs
- toe tapping
- finger tapping of thumb
Point to point movement examples
- eyes closed, pt points finger to nose
Gait examples
heel to toe, on heels or toes, knee bend
Stance examples
- Romburg test
- pronator drift
Basic + examine
- orientation & LOC (AOx3)
- pupils (PERRLA)
- push/pull (5/5 strength on upper & lower extremities bilaterally)
- EOMS (EOMS intact bilaterally)
- visual fields by confrontation (visual fields full by confrontation)
- facial palsy (no facial palsy)
- pronator drift (no pronator drift)
- speech
* follows commands, able to smile, raise eyebrows symmetrically
