Neurologic Assessment - Exam 6 Flashcards
With what glascow coma scale would you intubate a patient?
GCS less than or equal to 8
What are the criteria for glascow coma scale for infants?
Eye opening: Spontaneously, To speech, To pain, No reponse
Best Verbal Response: Coos, babbles, Irritable, cries, Cries to pain, Moans, grunts, No response
Best Montor Response: Spontaneous, Localizes pain, withdraws from pain, flexion (decorticate), extension, decerebrate), no response
What are the criteria for the glascow coma scale for a child/adult?
Eye opening: spontaneously, to command, to pain, no response
Best verbal response: oriented, confused, inappropriate words, incomprehensible, no response
Best motor response: obeys commands, localizes pain, withdraws from pain, flexion (decorticate), extension (decerebrate), no response)
What is a normal GCS score?
15
What is the progression of deteriorating brain function?
Level of consciousness deteriorates and improves in a perdictable pattern (except in direct and massive brain damage). Progressive loss of the higher levels of function occurs initially then the more primitive levels, and finally the life-sustaining functions. A diminished level of consciousness and behavior changes are early manifestations of cerebral involvement. The midbrain and brainstem functions are affected sequentially with characteristic changes in motor function, pupillary response and breathing patterns.
What is the progression of level of consciousness?
- Alert, oriented to time, place, and person
- Responds to verbal stimuli, decreased concentration, agitation, confusion, lethargy, disoriented
- Requires continuous stimulation to rouse
- Reflexive positioning to pain stimulus
- No response to stimuli
What is the progression of pupillary response?
- Brisk and equal; pupils regular
- Small and reactive
- Pupils fixed (nonreacive) in midposition
- Pupils fixed in midposition
What is the progression of motor response?
- Purposeful movement; responds to commands
- Decorticate positioning with upper extremity flexion (flexion positioning)
- Decerebrate positioning with adduction and rigid extension of upper and lower extremities
- Extension of upper extremities with flexion of lower extremities or flaccidity
What is the progression of breathing?
- Regular pattern with normal rate and depth
- Yawning, sighing respirations
- Cheyne-Stokes respirations with cresscendo-decrescendo pattern in rate and depth followed by periods of apnea
- Central neurologic hyperventilation with rapid, regular, and deep respirations; apneustic breathing with prolonged inspiration and pauses at full inspiration and following expiration
- Cluster or ataxic breathing with irregular pattern and depth of respirations; gasping respirations or apnea
What are gerontological considerations?
- Reduction in total brain weight
- Loss of neurons and changes in neurotransmitters
- Decrease in blood flow to the cerebrum (20%)
- Decreased CSF production
- Decrease in cerebellar function can lead to impaired balance/coordination
- Decreased sensory fibers can lead to altered perception of touch and pain
- Decrease in thermal sensitvity (hot-cold)
- Nerve conduction slows
- Decreased reaction time
- Pupil size diminishes, pupils react more slwoly to light and dark
What are the brain fast facts?
- Only 1-2% of body weight
- Receives 15% of rest cardiac output
- Accounts for 20% of total body oxygen consumption
- Cerebral blood flow (50ml/100gm of tissue) remains constant over a wide range of BP and intracranial pressure due to autoregulation of cascular resistance
What is the central nervous system?
Made up of the brain and spinal cord
What is the spinal cord?
A bundle of neurons that transmit information in ascending and descending tracts
What is the brain?
One function is expression of language VIA broca’s area
What is the brainstem?
Contains the midbrain, pons, medulla, and reticular formation, where the respiratory and vasomotor centers are located
What is the cerebrospinal fluid?
Circulates within the subarachnoid space and provides a fluid cushion for the brain and spinal cord
What is a neurotransmitter?
A chemical agent involved in the transmission of an impulse across the synaptic cleft
What is the peripheral nervous system?
Includes all neuronal structures that lie outside the CNS
What are the spinal nerves?
Each one contains motor and sensory nerve fibers
What are the cranial nerves?
12 pairs of nerves that may be motor, sensory, or both
What is the autonomic nervous system?
Controls involuntary functions of cardiac and smooth muscle and glands
What is the blood brain barrier?
Protects the brain from foreign substances in the blood that may injure the brain
What is the function of the frontal lobes?
- Memory retnetion
- Higher cognitive functions
- Voluntary eye movements
- Speech
- Voluntary motor movement
What is the function of the parietal lobes?
Spatial information
What is the function of the temporal lobes?
- Receptive speech
- Integration of somatic, visual, and auditory data
What is the function of the occipital lobe?
- Vision
- Visual image interpretation
What is the function of the cerebellum?
- Coordinate voluntary movement
- Controls balance and coordination
What is the function of the brainstem?
- Regulation of basic body function
- Vasomotor center (BP)
- Respiratory center
Why should the RN have some knowledge about the location of different brain functions?
Injury or disease to a specific area (eg temporal lobe on left) will cause a specific symptoms (expressive aphasia (anterior temporal) or receptive aphasia
What is the oculomotor nerve function and nursing assessment?
Nerve III
Pupil reaction (parasympathetic)
Eye movements (motor)
Check pupil reaction to light. Have patient follow your finger with their eyes up, down, side to side.
What is the trigeminal nerve function and nursing assessment?
Nerve V
Facial sensation (sensory)
Mastication (motor)
Can patient feel light touch or pin pricks on face? Assess ability to chew (do not use your fingers!)
What is the facial nerve function and nursing assessment?
Nerve VII
Face movement (motor)
Taste, anterior tongue (sensory)
Have patient raise eyebrowns, squeeze eyes shut tight, smile and show all teeth
What is a lumbar puncture?
Procedure where patient lies on their side in the fetal position and sterile needle is passed between lumbar vertebrae. Manometer attached to the needle to obtain a CSF pressure. CSF drained into a series of tubes.
What is the purpose of a lumbar puncture?
- Analyze CSF
- Should not contain blood
- Should not contain bacteria
- Glucose is normal. Should be 40-70 mL/dL
- Check pressure
What are the nursing considerations for lumbar puncture?
- Keep patient still during procedure
- Have patient empty bladder before procedure
- Assist with positioning the patient
- Ensure proper labeling
- Do not perform if skin infection or tumors around insertion site
- Inform patient that they may feel radiating pain down the leg
- Lay flat after procedure to prevent spinal headache
- Monitor for HA, menigeal irritation nucal rididity (resistance to flexion of neck)
- Monitor for s/sx of trauma
- Encourage fluids
- Administer analgesia
What is a cerebral angiogram?
Catheter goes into femoral, up through aortic arch and into base of carotid or vertebral artery, inject dye, take pictures, timed sequence radiographic images are obtained as the contrast media flows through the vasculature
What is the purpose of a cerebral angiogram?
Helps to localize and determine presence of abscesses, aneurysms, ateriovenous malfunctions, arterial spasms, and certain tumors
What are the nursing considerations for cerebral angiogram?
- NPO before procedure
- Check allergies
- Determine if meds are to be with held
- Warm, flsuhed feeling in head when dye is injeccted
- Lay still throughout procedure
- VS throughout procedure
- Observe for reactions
- Monitor for hemorrhage and bleeding at puncture site
- Increase fluids
- Monitor for change in neuro status
What is an electroencephalogram (EEG)?
Record electrical activity of the surface cortical neurons of the brain. Can be continuous at some institutions.
What is the purpose of an EEG?
- To evaluate the effects of bright lights, loud noises on electrical activity of brain
- Evaluate cerbral d/o
- Evaluate CNS effects of many metabolic and systemic diseases
- To determine brain death
- Seizures (does brain react to stimuli)
What are the nursing considerations for EEG?
- Let patient know that no shock is given
- Limit any other external stimuli
- Find out which meds should be held, if any
- Cleanse hair after the procedure to remove electrode paste
What are the basic concepts of neuro patients?
- Neuro patients almost never suddenly deteriorate
- We often do not stimulate a patient enough to get the highest level of response
What are types of pain stimuli?
- Central (brings about a response from the brain)
- Trapezius squeeze
- Sternal rub (not recommended due to potential for skin injury)
- Supraorbital pressure
- Mandibular pressure
- Peripheral or spinal response (elicits a spinal response)
- Assessed if a patient’s limb has not moved or if patient remains unconscious
- Nailbed pain
Apply pain for at least 15 seconds but no more than 30 seconds
How do you assess arousal/wakefullness?
Function of the brain stem, clinical indication is imply the patient opening eyes
How do you assess awareness?
The cerebral cortex, the thinking part of the brain, is functioning; individual’s expression that he/she can interact with and interpret the environment
- Orientation
- Time (usually lost first)
- Person
- Place
- Attention span
- Language
- Speak clearly
- Slur words
- Correct self
- Use incorrect names
- Memory
- Include short term and long term
- Assess judgement - what would you do if a threater were on fire?
What is decortication?
Flexion
Functioning without the higher centers of the brain. Arms come up toward the core of the body to painful stimuli
What is decerebration?
Extension.
Only brain stem is functioning. Arms extend down and outward to painful stimuli
What is the motor strength test grading?
- 5/5 normal ROM against full resistance
- 4/5 ROM with moderate resistance
- 3/5 ROM against gravity
- 2/5 rolls but cannot lift
- 1/5 contraction without movement
- 0/5 no movement
What is pronator drift?
Patient is unable to hold arms up with eyes closed for an extended period of time, sign of deterioration of motor strength
What is dysmetria?
Inability to point finger to the nose (FTN), demonstrated by past pointing
How do you test lower extremities for coordination?
Touch hell to opposite shin and slide down leg
What is rapid alternating movements (RAMS)?
Ask the patient to play the piano, note discrepancy in speed and smoothness (dysdiadochokinesia)
What do contricted pupils suggest?
Patient has recieved narcotic, don’t rule out neurologic event
What do pinpoint pupils suggest?
Pinpoint pupils in stroke patients suggest damage to pons
What do bilaterally dilated pupils suggest?
Hypoxemia
What does oval shaped pupils suggest?
increased ICP
What is anisocoria?
grossly unequal pupils
What are fixed pupils?
no response. confirm with a consensual response by shining light in opposite eye and watching reaction in fixed eye
