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Nursing Funds > Neurological Assessment > Flashcards

Neurological Assessment Flashcards

1
Q

Detailed neurological assessments are performed when the patient’s condition requires it, such as with a______, etc.

A

stroke

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2
Q

: level of consciousness (LOC), physical status, chief complaint.

A

varibles that must be considered during evaluation

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3
Q

reading material or a Snellen chart; vials with different aromas and sugar, salt, and lemon; a cotton swabs or cotton balls; a tongue blade; a penlight; two test tubes (one with hot water and one with cold); tuning fork; and a reflex hammer. (you will only need your penlight for your mastery, though).

A

stuff you need for a full neuro assessment

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4
Q

ADL abilities
Changes in sensation
Neurological “red flags”
Headache
Dizziness
Hx of head trauma, head surgery, or loss of consciousness
Seizure

A

health history that needs to be gathered

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5
Q

Level of Consciousness
Mental Status/Orientation
Cognitive Function
Cranial Nerves
Sensory/Motor Function

A

physical assessment findings

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6
Q

If the patient has _______, you will want to ask the patient to describe them (do they cause them to have convulsions, or only a brief loss of awareness?)

A

seizures

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7
Q

Ask the family about any behavior changes that might indicate ________, such as confusion, disorientation, or restlessness. Also consider the medications, alcohol, or recreational drugs they are taking and if any could cause toxicity or neurological side effects.

A

delirium

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8
Q

______ is first assessed when you begin the physical examination. Are they alert?

A

LOC

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9
Q

Fully awake
Responds to all stimuli
Able to follow verbal commands
May not be fully oriented, though

A

Alter LoC

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10
Q

Drowsy or asleep most of the time
Can be awaken by gentle shaking, saying patient’s name
Makes spontaneous movements
Forgetful
Delayed response to verbal commands

A

Lethargic LOC

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11
Q

Extreme Drowsiness
Minimally responsive
Barely follows commands
Vigorous stimulation to awaken
Difficulty staying awake

A

obtunded

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12
Q

Unconscious most of the time
No spontaneous movement
Awakens briefly only with repeated vigorous stimulation
Responds in groans, moans
Responds to painful stimuli with purposeful movements

A

semi-comatose or stuporous

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13
Q

No response to verbal or painful stimuli
Cannot be awakened, does not speak
Some reflexes may be present
Decorticate position OR…
Decerebrate position

A

comatose

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14
Q

posture is considered abnormal extension

A

decerebrate

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15
Q

posture is abornmal flexion

A

decorticate

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16
Q

decerebrate and decorticate posture both indicate?

A

severe brain injury

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17
Q
A

Decerebrate posture

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18
Q
A

Decorticate posture , corticospinal tracts

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19
Q

Normally, a patient will quickly respond to your questions and express their thoughts in a logical manner.
If they display a lowered state of consciousness, you will need to use the __________ to measure their consciousness.

A

Glasgow Coma Scale (GCS)

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20
Q

. The ______ the total score, the better the neurological function

A

higher

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21
Q

A GCS of 13 to 15 = ______

A

mild brain injury

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22
Q

9 to 12 =

A

moderate brain injury

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23
Q

8 or less =

A

severe brain injury.

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24
Q

Normally a person’s speech has _______, is clear, strong, has appropriate volume, flows well, is spontaneous, and articulate (coherent)

A

inflections (not monotone)

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25
Q

For ineffective speech, you need to assess further for _______.

A

aphasia

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26
Q

_______ is when a person loses the ability to understand or express speech. This is caused by brain damage from an injury or disease. There are different types of aphasia.

A

Aphasia

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27
Q

. 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.

A

Motor or Expressive aphasia
Broca’s Aphasia

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28
Q

Where the patient 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).

A

Sensory or receptive aphasia
Wernicke’s Aphasia

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29
Q

Aphasia can be _________ aphasia, where the patient lacks both expressive and receptive language.

A

Global

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30
Q

You will test cognitive function by asking the patient a series of ______

A

questions

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31
Q

You will need to assess a patient’s______ ______ ______ memory.

A

immediate, recent, and past

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32
Q

For _________ _______ the patient will repeat a series of 5 to 8 numbers in the order presented or reverse order (whichever you specify) (example: 7, 4, 3, 1, 8)

A

Immediate recall

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33
Q

For ______, you can ask the patient what they had for breakfast (make sure you can verify this), or you can have the patient repeat three unrelated objects at the beginning of assessment (bird, pen, apple), then ask them to name the objects again at the end of the assessment. They should be able to recall all three.

A

recent memory

34
Q

For__________, you can ask the patient about an important date, such as their birthday or anniversary, or even their maiden name, but again you must be able to verify that it is correct.

A

past memory

35
Q

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

A

Knowledge

36
Q

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

A

Abstract Thinking

37
Q

______ = Name simple, related concepts and have the patient identify how they are associated. This tests higher levels of cognitive functioning.
A carrot is to a vegetable as an apple is to a _______(fruit).

A

Association

38
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

Judgment

39
Q

CN 1

A

(olfactory = sense of smell) ask the patient to identify 2 different nonirritating aromas such as coffee and vanilla. Be sure to test each nostril

40
Q

CN 2

A

(optic = visual acuity) Using the Snellen chart or having the pt read printed material with their glasses on if they wear them.

41
Q

CN III

A

(Oculomotor = extraocular eye movement, pupil constriction, opening the eyelids) Assess the six directions of gaze and measure PERRLA.

42
Q

CN IV

A

(Trochlear = downward and inward eye movements) Also assessed with the six directions of gaze.

43
Q

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

A

anisocoria

44
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

45
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

46
Q

When only one pupil is large, fixed, and dilated, this indicates a______ of the ______ of the brain , which affects cranial nerve 3..

A

herniation, temporal lobe, (uncal herniation)

47
Q

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

A

Miosis

48
Q

______ that medications, recreational drugs, trauma, and adrenaline can dilate the pupils, as well as a dark environment.

A

Remember

49
Q

______ = sensory of facial skin and movement of the jaw muscles. lightly touch cornea of the eye with a wisp of cotton to assess corneal reflex.
Measure sensation of light touch across the skin of the face.
Palpate the temples as the patient clenches their teeth.

A

CN V Trigeminal

50
Q

_______ = lateral movement of the eyes. Assess with the six movements of gaze.

A

CN VI Abducens

51
Q

______ = facial expression and taste. As the pt smiles, frowns, puffs out cheeks, and raises and lowers eyebrows, look for any asymmetry. (should be symmetrical).

A

CN VII facial

52
Q

__________ = hearing) Assess the pt’s ability to hear spoken word.

A

CN VIII ( Auditory

53
Q

______ = taste and ability to swallow. Ask the pt to identify sweet and sour tastes on the posterior 1/3 of the tongue.
Use a tongue blade to elicit a gag reflex.

A

CN IX Glossopharyngeal

54
Q

______ = 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)
Ask the pt to say “ah” and observe movement of the pharynx and palate.
Assess for hoarseness of speech.
Assess heart rate and presence of peristalsis (active bowel sounds)

A

CN X Vagus

55
Q

___________ = Movement of the head/shoulders. Ask the pt to shrug their shoulders and turn their head against passive resistance.

A

CN XI Accessory

56
Q

______________ = position of the tongue. Ask the pt to stick out their tongue to midline and move it from side to side.

A

CN XII hypoglossal

57
Q

Different nerve pathways relay sensations

A

Dermatomes

58
Q

A _________ 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 ___________ zones, that are pictured on the slide.

A

dermatome

59
Q

To assess______, 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

sensory

60
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 you know when they feel dull or sharp sensations.

A

Pain sensory 

61
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 

62
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 

63
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

64
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

65
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

66
Q

Pain
Temperature
Light touch
Vibration
Position
Two-point discrimination

A

Sensory Testing

67
Q

Coordination
Balance
Romberg’s test
Another test involves asking the patient to walk a straight line by placing the heel of one foot directly in front of the toes of the other foot

A

Motor Function

68
Q

______ ______ includes your musculoskeletal assessments, but for the neuro assessment you will also be examining the patient’s coordination and balance, which are controlled by the ______ of the brain.

A

Motor function, cerebellum

69
Q

______ 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.
You can also have the patient pat their knees with the palms of their hands, then alternate patting them with the back of their hands.
Then have the patient rapidly touch each finger to their thumb of the same hand. This movement should be smooth but remember that the non-dominant hand may be more awkward than the dominant hand.
For the lower extremities, have the patient lay down with their legs extended, and you will place your hands on the balls of their feet. Have the patient tap your hands with their feet as fast as possible. Look for their speed and smoothness of movement. Older adults will have slower movement with less rhythm.

A

Coordination

70
Q

To test balance, you will perform the ______ ______, 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.

A

Romberg’s test

71
Q

Normally, the patient might have slight swaying, but should not lose balance. Loss of balance is a _______ Romberg test, which is abnormal.

A

positive

72
Q

_______________ _____________ are commonly assessed by nurses in OB and Neuro settings. This helps assess peripheral spinal nerve function.

A

Deep tendon reflexes (DTRs) and cutaneous reflexes

73
Q

Each tendon corresponds to different segments of the spine. Three frequently assessed reflexes are the ______ ______ ______.

A

bicep, patellar, and plantar (Babinski)

74
Q

The bicep and patellar are ______ and the plantar is a ______.

A

DTRs, cutaneous reflex

75
Q

For the ______, you are actually placing your thumb over the tendon and tapping your thumb with the patient’s palm turned down. For the _____, you tap directly on the tendon.

A

bicep, patellar

76
Q

For the ________, 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 adult, the toes should curl __.

A

IN

78
Q

For a newborn, the toes should ________.

A

fan out

79
Q

Grade reflexes:
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

A
80
Q

For older adults, it is normal for them to have ______ reflexes.

A

diminished

81
Q

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

A

positive

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