Neuro Assessment Flashcards
What are the 3 signs/components of Cushing’s triad?
1) bradycardia (slow and bounding)
2) increased SBP and widening pulse pressure
3) irregular and decreased respirations
What is the significance of Cushing’s triad?
it is a LATE sign of increased ICP
Describe decorticate and decerebrate posturing and which areas of the brain are likely affected.
Decorticate: flexed upper extremities and extended lower extremities
- injury of corticospinal tract (above brainstem)
Decerebrate: rigid extension, arms pronated; wrists, fingers, and jaw flexed; back arched with lower extremities extended and feet plantarflexed
- injury between midbrain and brainstem
What are the 3 sections that make up the Glasgow Coma Scale (GCS)?
1) Eye opening response /4
2) Motor response /6
3) Verbal response /5
Total score out of 15
What score on the GCS indicates a coma?
less than 8
Match the lobes of the brain: Frontal Temporal Parietal Occipital
with the brain functions: vision judgment, problem solving, insight sensory, proprioception auditory, speech, taste
Frontal: judgment, problem solving, insight
Temporal: auditory, speech, taste
Parietal: sensory, proprioception
Occipital: vision
Explain the difference between injury of upper motor neurons (UMN) vs. lower motor neurons (LMN)
UMN lesions: spasticity, hyperreflexia
LMN lesions: weakness, paralysis, areflexia, flaccidity
Describe the 5 grades of muscle strength
0 - no contraction 1 - slight contraction 2 - full PROM 3 - full ROM 4 - full ROM against some resistance 5 - full ROM against full resistance
Describe the assessment for the following cranial nerves: I II III, IV, VI V VII VIII IX X XI XII
I - smell II - vision III, IV, VI - pupil response V - chewing VII - facial symmetry VIII - hearing IX - swallow X - speech XI - shoulder shrug XII - tongue movement
What are the classifications and subtypes of stroke
Ischemic stroke - thrombotic and embolic
Hemorrhagic stroke - intracerebral or subarachnoid
What is the best treatment for hemorrhagic stroke?
evacuate the hematoma if possible, to limit injury and damage
in subarachnoid hemorrhage, vasospasm is controlled with nimodipine (calcium channel blocker)
What is the best treatment for ischemic stroke?
tPA if given within 3 hours of stroke symptom onset
What medications are given for prophylaxis and treatment of ischemic stroke?
Aspirin
Clopidogrel (Plavix)
Aspirin-dipyridamole (Aggrenox)
Warfarin - reserved for patient at risk for thromboembolic strokes due to AFib, coagulation disorders, or other cardiogenic sources
What nursing interventions should be started to treat ICP that occurs with occlusion of cerebral arteries?
treat hypoxia, hypercarbia and hyperthermia
elevate HOB to 30 degrees to promote drainage
osmotic diuretics
What parameters for blood glucose and BP should be monitored before starting treatment?
BP: do not treat unless DBP > 120 or SBP > 220
BG: treat hyperglycemia with IV insulin when > 200 mg/dL
What is the pneumonic for the cranial nerves - names and functions?
Names: Oh, Oh, Oh, To Touch And Feel Very Green Vegetables - AH!
Some Say Marry Money But My Brother Says Big Brains Matter Most
What are 4 indications for neurological assessment?
1) on admission
2) after surgery
3) after medical interventions
4) changes in patient status and condition
Which part of the GCS includes pupillary response?
Eye opening
What are the 5 levels of consciousness?
“FLOSC”
Full - alert, attentive, and follows commands
Lethargy: drowsy but awakens, answers questions and follows commands, does slowly and inattentively
Obtunded: difficult to rouse and needs constant stimulation to follow a simple command; may respond verbally with 1-2 words but will drift back to sleep between stimulation
Stupor: patient rouses to vigorous and continuous stimulation; usually painful stimulus is required; may moan briefly but does not follow commands
Coma: patient does not respond to continuous or painful stimuli; does not move except possibly reflexively; does not make any verbal sounds
What is the sequence of neurological deterioration?
1) Loss of consciousness - orientation is lost first –> patient becomes difficult to rouse, needs increased stimulation
2) Changes in motor function: strong –> moderate
3) pupillary changes
- pupils become unequal and reaction changes from brisk to sluggish to fixed and dilated
4) vital signs - Cushing’s triad
