neuro disorders

Question 1

neuro assessment

Answer 1

LOC ( alert, lethargic, obtunded, comatose)
Orientation (person, time, place)
Affect
Mood
Speech: clarity/tone/ articulation
Cognition

Question 2

movement assessment

Answer 2

Voluntary control/involuntary movements
Tremors
Twitches
Balance and gait
- movement of feet
- coordination

Question 3

vitals to focus on

Answer 3

temp
blood pressure

Question 4

motor

Answer 4

Motor strength
- Squeeze hands
- Palmar drift test

Motor response
- Spontaneous or to pain
- Size
- Symmetry
- Tone
- Strength

Coordination

Question 5

pupils

Answer 5

Pupils:
PERRLA
- Pupils, Equal, Round and Regular in shape, Reactive to Light and Accommodation.
- cranial nerve 2 and 3
- narcatoics and pain make wide

Question 6

Lumbar puncture

Answer 6

Procedure that inserts a needle into the subarachnoid space of spineProcedure that inserts a needle into the subarachnoid space of spine

Question 7

nursing intervention for lumbar puncture

Answer 7

• Verify informed consent has been signed.
• Have patient empty bladder and bowel.
• Position patient on side, with knees pulled toward chest and chin tucked down (fetal position).
• Assess patient and help provider collect fluid.
• Encourage fluids post procedure.
• Assess puncture site for redness, swelling, clear drainage.
• Assess movement of extremities

Question 8

Computed tomography (CT SCAN)

Answer 8

• Check allergies to iodine, contrast dyes, shellfish.
• Assess BUN and creatinine & GFR .
• Encourage fluids post procedure.

Question 9

Cerebral arteriography:

Answer 9

Injection of dye to visualize cerebral arteries.
- Same preparation as CT scan.
- Keep patient NPO 4-6 hours before procedure.
- Mark peripheral pulses.: check for clots (mark pedal pulse prior)
- Monitor LOC post procedure
- Check for bleeding or hematoma at insertion site.

Question 10

Electroencephalogram (EEG):

Answer 10

Noninvasive assessment of electrical activity of brain.

Question 11

why diseases need an eeg

Answer 11

Seizure disorders
Head injuries
Tumors
Infections
Degenerative disease
Confirm brain death

Question 12

Magnetic Resonance Imaging (MRI):

Answer 12

Imaging produced through interaction of magnetic fields, radio waves, and atomic nuclei

Question 13

mri contrainindications

Answer 13

• Patient must remove all metal objects.
• Contraindicated for pacemakers, stents, and surgical clips.
• Titanium joints are ok.
• Assess for claustrophobia.
• Assess patient’s ability to lie still in a supine position for 60 min.

Question 14

interventions for mri claustraphobia

Answer 14

• music
• headphones
• benzos
• prophanol and airway

Question 15

Cranium Anatomy

Answer 15

The skull has three essential components:

Brain tissue
Blood
Cerebrospinal fluid (CSF)

removing part

Question 16

Glasgow Coma Scale (GCS) measures

Answer 16

Eye Opening, Verbal Response, Motor Response are given a numeric value
The total GCS score is the sum of the numeric values.

Question 17

15 and 3 and 8 on gcs

Answer 17

15 = a fully alert person, and the lowest score is 3.
A GCS score of 8 or less indicates a coma

Question 18

GCS scoring

Answer 18

U = Untestable
1-4= Eyes Open
1-5= Best Verbal Response
1-6= Best Motor Response

Table 57-5/page 1365