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Nursing Funds > Neurological > Flashcards

Neurological Flashcards

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1
Q

change in behavior…

A

that might indicate delirium, such as confusion, disorientation, or restlessness.

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2
Q

what do you need to do for mental status?

A
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3
Q

what should you ask a patient when determining if a patient is alert

A

Person : Tell me your name.
Place: Where are you at?
Time: What month is it, or what season is it?
Situation: Do you know why you’re here?

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4
Q

what is required to know when level of awareness?

A

Fully awake, responding to verbal stimuli, able to follow commands
Person, Place, Time, Situation
Normal = Alert and oriented x4

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5
Q

Fully awake
responds to all stimuli
able to follow verbal commands
may not be fully oriented, though

A

alert

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6
Q

drowsy or asleep most of the time
can be awaken by gentle shaking, saying name
makes spontaneous mvmt
forgetful
delayed response to verbal commands

A

lethargic

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7
Q

extreme drowsiness
minimally
responsive
barely follow commands
vigorous stimulation to awaken
difficult staying awake

A

obtunded

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8
Q

unconscious most of the time
no sponyaneous mvmt
awaken briefly only with repeated vigorous stimulation
responds in groans, moans
responds to painful stimuli with purposeful mvmt

A

semi-comatose

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9
Q

no response to verbal or painful stimuli
cannot be awaken, does not speak
some reflexes may be present
decorticate position OR…
decerbrate position

A

comatose

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10
Q

posture is considered abnormal extension see the top picture where the arms and legs are extended, and the wrists are pronated with the fingers and feet flexed.

A

Decerebrate

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11
Q

posture is abnormal flexion  see the bottom picture where the arms are pulled inward and the elbows, wrists, and fingers are flexed.

A

Decorticate

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12
Q

when should you use the glasgow coma scale (gcs)?

A

if patient displays a lowered state consciousness
there are three categories
1. eye opening
2. verbal response
3. best motor response

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13
Q

what do the score of the gcs scale imply?

A

The higher the total score, the better the neurological function. A GCS of 13 to 15 = mild brain injury; 9 to 12 = moderate brain injury; 8 or less = severe brain injury.

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14
Q

what two places can you assess appearance and behavior?

A

can be part of the general survey or neurological assessment

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15
Q

what should you assess when determining appearance and behavior

A

eye contact
behavior appropriate to the conversation and situation
good hygiene and dressed appropriately for the weather
speech is articulate and appropriate

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16
Q

what should a pt’s speech normally sounds like?

A

inflections (not monotone), is clear, strong, has appropriate volume, flows well, is spontaneous, and articulate (coherent)

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17
Q

what does abnormal speech sounds like?

A

may be slow, rapid, soft, loud, or unclear. It may also be ineffective with hesitancy, misuse of words, or have missing or added letters and words.

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18
Q

what is aphasia

A

ineffective speech; when a person loses the ability to understand or express speech. This is caused by brain damage from an injury or disease

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19
Q

what is broca’s aphasia? motor or expressive aphasia

A

motor or expressive aphasia:
The patient cannot speak or write appropriately because they because they have trouble producing the speech or they have trouble finding the right words. They still understand the written and verbal speech but are unable to express it.

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20
Q

what is wernicke’s aphasia?

A

sensory or receptive aphasia; where the pt cannot understand written words or speech; they can speak but often use made up words or have word salad (mixing up random words or phrases)

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21
Q

what is global aphasia?

A

where the pt lacks both expressive and receptive language

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22
Q

what should you do to determine a pt immediate recall?

A

repeating a series of numbers

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23
Q

what should you do to determine a recent memory?

A

3 unrelated objects or “what did you have for breakfast?”

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24
Q

what should you do to determine a remote (past) memory?

A

what is your birthday

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25
Q

ask the patient what they know about their illness. This will help you determine their ability to understand or learn.

A

knowledge

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26
Q

you will be assessing the patient’s ability to interpret abstract ideas or concepts. Have them explain common phrases like, “Don’t Count your chickens before they are hatched.”

A

abstract thinking

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27
Q

when assessing abstracting thinking what should you keep in mind?

A

A patient with altered mental status might interpret this literally or just repeat the words. Just make sure there isn’t a cultural barrier to their understanding the phrase.

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28
Q

Name simple, related concepts and have the patient identify how they are associated. This tests higher levels of cognitive functioning.

A

association

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29
Q

what is an association example

A

carrot is to a vegetable as apple is to fruit

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30
Q

Try to measure the patient’s ability to make logical decisions and conclusions with questions like “What would you do if you became ill at home?” Normally a patient will make a logical decision.

A

judgement

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31
Q

what is the CN 1

A

olfactory; sense of smell

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32
Q

how should you test CN i

A

use two different smells and test each nostril

33
Q

what is the CN 2

A

optic; visual acuity

34
Q

how should you test the CN 2

A

Using the Snellen chart or having the pt read printed material with their glasses on if they wear them.

35
Q

what is the CN 3

A

oculomotor; extraocular eye mvmt

36
Q

what is the CN 4

A

trochlear; downward and inward eye mvmt; assessed with the six direction of gaze

37
Q

Unequal pupil sizes. A small percentage of people normally have anisocoria. Should be no more than 1 mm difference. Unequal pupil size can indicate central nervous system disease.

A

Anisocoria

38
Q

fixed and dilated pupils. Can be caused by severe brain damage or drug induced. Brain damage usually indicated by “blown pupils” largely dilated and fixed.

A

Mydriasis

39
Q

there is no reaction to light, but the pupil does constrict with accommodation. The pupils will be small and irregular, bilaterally. Causes are central nervous system syphilis, brain tumor, meningitis, and chronic alcoholism.

A

Argyll Robertson Pupil

40
Q

what indicates a herniation of the temporal lobe of the brain (uncal herniation)? what CN does it affect?

A

when only one pupil is large, fixed, and dilated; CN 3

41
Q

constricted and fixed pupils. Can be drug induced or occur with iritis or damage to the pons of the brain.

A

Miosis

42
Q

what are some things that can dilate the pupils?

A

medications, recreational drugs, trauma, adrenaline, and dark environment

43
Q

what is the CN 5

A

trigeminal; sensory of facial skin and mvmt of the jaw muscles; lightly touch cornea of the eye with wisp of cotton to assess corneal refles

44
Q

how should you measure the CN 5

A

Measure sensation of light touch across the skin of the face.
Palpate the temples as the patient clenches their teeth.

45
Q

what is the CN 6

A

lateral mvmt of the eyes

46
Q

how should you asses the CN 6

A

assess with the six mvmt of gaze

47
Q

what is the CN 7

A

facial; facial expression and taste

48
Q

how should you assess

A

as the pt smiles, frowns, puffs out cheeks, and raises and lowers eye. look for any asymmetry (should be symmetrical)

49
Q

what is the CN 8

A

auditory; hearing

50
Q

how do you assess CN 8

A

assess the pt’s ability to hear spoken words

51
Q

what is the CN 9

A

glossopharyngeal; taste and ability to swallow

52
Q

how do you assess CN 9

A

ask pt to identify sweet and sour tastes on the posterior 1/3 of the tongue; use a tongue blade to elicit a gag reflex

53
Q

what is the CN 9

A

Vagus = sensation of the pharynx, movement of vocal chords, parasympathetic innervation to mucous membrane glands of the pharynx, larynx, organs in the neck, thorax [heart and lungs], and abdomen

54
Q

how do youasses CN 10

A

Assess for hoarseness of speech.
Assess heart rate and presence of peristalsis (active bowel sounds)

55
Q

what is the CN 11

A

accessory; movement of the head/shoulder

56
Q

how do you assess CN 11

A

ask pt to shrug their shoulders and turn their head against passive resistance

57
Q

what is the CN 12

A

hypoglossal; position of the tongue

58
Q

how do you assess the CN 12

A

ask the pt to stick out their tongue to midline and move it from side to side

59
Q

Different nerve pathways relay sensations. A dermatome is an area of skin that is supplied mainly from one spinal cord segment through a particular spinal nerve. You can assess each major sensory nerve by knowing the dermatome zones, that are pictured on the slide.

A

dermatomes

60
Q

To _______ _______, you want to have the patient close their eyes, so they don’t see where each stimulus touches the skin. You will ask the patient to describe when, what, and where they feel each stimulus. You also want to use a random pattern, so they don’t guess.

A

assess sensory

61
Q

you press the end of a paper clip or wooden end of a cotton swab against the skin and ask the patient to let yknow when they feel dull or sharp sensation

A

pain sensory

62
Q

take a test tube filled with hot water and one with cold water and touch the patient’s skin with each to identify hot or cold sensation.

A

temperature

63
Q

use a cotton ball and apply a light wisp of cotton to different points along the skin and have the patient tell you when they feel the cotton ball.

A

light touch

64
Q

take a vibrating tuning fork and place the stem on the end joints of the fingers, big toe, elbow, and wrist, having the patient tell you when they feel the vibration (not pressure).

A

vibration

65
Q

grasp a finger or a toe and by the sides with your thumb and index finger and move the patient’s toe or finger up and down, asking them to state when it is up or down.

A

position

66
Q

take two ends of paper clips and apply each, simultaneously to the skin surface, asking the patient whether they feel one or two pricks. Find the distance between the paper clips that they no longer can tell that there are two points.

A

two-point discrimination

67
Q

when would you use the romberg’s test

A

to test balance

68
Q

what will you be do for neur assessment when thinking about motor fuction

A

you will also be examining the patient’s coordination and balance, which are controlled by the cerebellum of the brain.

69
Q

what should you do for coordination?

A

have the patient hold their arms out to their sides and then touch each finger to their nose. Have them do this with their eyes open, then closed. This movement should be smooth.

70
Q

what is the romberg’s test?

A

where the patient stands with their feet together and arms at their sides (eyes open, then closed). You are watching to see if they sway or fall side to side. For safety, stand at the patient’s side with your arms in front and behind them. Normally, the patient might have slight swaying, but should not lose balance. Loss of balance is a positive Romberg test, which is abnormal.

71
Q

Grade reflexes:

A

0: no response
1+: sluggish/diminished
2+: active/expected response
3+: more brisk than expected, slightly hyperactive
4+: brisk and hyperactive with intermittent or transient clonus

72
Q

commonly assessed by nurses in OB and Neuro settings. This helps assess peripheral spinal nerve function. Each tendon corresponds to different segments of the spine

A

Deep tendon reflexes (DTRs) and cutaneous reflexes

73
Q

what are the three frequently assess reflexes

A

bicep, patellar, and plantar (babinski)

74
Q

you are actually placing your thumb over the tendon and tapping your thumb with the patient’s palm turned down

A

bicep

75
Q

you tap directly on the tendon

A

patellar

76
Q

you are taking the handle end of the reflex hammer and lightly run it across the bottom of the patient’s foot, from heel to the ball of the foot, on the lateral aspect

A

Babinski

77
Q

For an ____, the toes should curl in. For a _____, the toes should fan out.

A

adults; newborn

78
Q

For the _____ _______, if the adult patient’s toes flare out, this is abnormal and documented as a positive Babinski reflex.

A

plantar reflex

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