Neurologic Assessment Flashcards
What factors should you know about an individual’s pain?
- location
- quality
- severity
- duration
- precipitating factors
- associated symptoms
- exasperation/diminished pain
- onset
What is the Wong-Baker Face Scale
A pain assessment
What do headaches signal in neurology?
Headaches can be a result of many different causes. Headaches are not a good indicator of neuro trouble.
What is vertigo?
Sensation of moving around in space or objects moving around a person. There are associated symptoms which can include lightheadedness, dizziness, and nausea (fall risk)
What should be assessed to determine cerebral function?
- mental status
- intellectual function
- thought content
- emotional status
- perception
- motor ability
- language ability
What is the typical mental status of someone who is alert?
Individual is able to open eyes spontaneously, can respond appropriately and briskly, and is oriented
What is the typical mental status of someone who is lethargic?
Individual opens eyes to verbal stimuli, is slow to respond but responds appropriately, has a short attention span, or may be obtunded (more depressed level of consciousness)
What is the typical mental status of someone who is in a stupor?
Individual responds to physical stimuli with moans and groans, is never fully awake, is confused, and speaks/communicates unclearly (word formation is difficult)
What is the typical mental status of someone who is semi-comatose?
Individual responds to painful stimuli (sternal rub), there is no conversation, and protective reflexes are present
What is the typical mental status of someone who is comatose?
Individual is unresponsive except to severe pain, does not have any protective reflexes, has fixed pupils, and does not have any voluntary movement
What does unconscious mean?
It is a non-medical word that ranges from stupor to coma
What is a persistent vegetative state?
Individual has no cognitive brain function, still has wake/sleep cycles, and has a very poor prognosis (3-6 months)
What does brain dead mean?
Individual has no brain function and only has reflexive movements
What are different types of stimuli that are used to get a response?
1) Voice
2) Touch
3) Shaking
4) Voice and shaking
5) Noxious/painful stimuli (sternal rub)
What are the natures of response to stimuli?
1) Eyes open
2) Remove stimuli
3) Abnormal posturing
4) No response
What is the Glasgow Coma Scale?
Most commonly used scoring system to describe level of consciousness in a person following a traumatic brain injury. The GCS is not typically used with children. The Pediatric Glasgow Coma Scale is used. The GCS is a strong predictor of patient outcome
Severe: GCS 8 or less (coma)
Moderate: GCS 9-12
Mild: GCS 13-15
GCS Eye Opening
Eye Opening: Spontaneous - 4 To speech - 3 To pain - 2 Nil - 1
GCS Motor Response
Best Motor Response: Obeys - 6 Localizes - 5 Withdraws - 4 Abnormal flexion - 3 Extension response - 2 Nil - 1
GCS Verbal Response
Verbal Response: Oriented - 5 Confused conversation - 4 Inappropriate words - 3 Incomprehensible sounds - 2 Nil - 1
What things should you look at when assessing someone’s appearance?
- grooming
- dress
- aids
- eye deviation
- skin
A visual assessment is used to identify signs of trauma (wounds, scrapes, ecchymosis - discoloration under skin due to bleeding etc.)
What does Battle’s Sign indicate?
Bruising over the mastoid suggests a skull fracture
What do Raccoon’s eyes indicate?
Periorbital edema and bruising suggests frontal-basal fracture
What does Rhinorrhea indicate?
Drainage of CSF from the nose suggests a fracture of the cribiform with torn meninges (commonly seen with gun shot wounds)
What does Otorrhea indicate?
Drainage of CSF from the ear suggests a fracture of the temporal bone with torn meninges
