📝 Neurological Assessment Flashcards
What are key focus areas in a neurological health history interview?
Headache, head injury, dizziness and vertigo, seizures, muscle control, senses, speech, memory, and cognition.
What three large areas of the brain are involved in regulating consciousness?
The reticular formation, the thalamus, and the cortex.
What are some causes of altered levels of consciousness?
Coma, substance abuse, confusion, certain medications, delirium, epilepsy, disorientation, low blood sugar, lethargy, stroke, and hypoxaemia.
What is the most widely recognised assessment tool of the level of consciousness?
The Glasgow Coma Scale (GCS).
What are the components of the Glasgow Coma Scale?
Eye opening, best verbal response, and best motor response.
How do you assess peripheral pain using the Glasgow Coma Scale?
Options include nail bed pressure and inter-phalangeal joint pressure.
What indicates normal pupillary function?
Pupils should be round, central, equal in size, and reactive to light.
What are some preparatory steps before commencing a neurological assessment?
Understanding the patient’s condition, considering personal preferences, ensuring gender appropriateness, cultural and linguistic considerations, family involvement, using functional equipment, and correct documentation.
What physiological parameters might be impacted by neurological injury?
Hypotension, hypertension, dysrhythmias, tachypnoea, temperature alterations, and hypoxia.
What is the purpose of a FAST assessment?
To quickly identify signs of a stroke: Facial drooping, Arm weakness, Speech difficulties, and Time to call emergency services.
What are the fundamental processes involved in the physiology of pain?
Transduction, transmission, perception, and modulation.
How does the body modulate pain?
Through the activation of descending neural pathways that inhibit pain transmission, using substances like endogenous opioids.
What distinguishes nociceptive pain from other types of pain?
It is the pain sensed by the nociceptors after tissue injury or inflammation.
How is acute pain different from chronic pain?
Acute pain has a sudden onset and is short-term, while chronic pain is constant, lasting for more than 3 to 6 months.
What myths about pain in adults and children should nurses and midwives be aware of?
For example, the myth that people with severe tissue damage always experience significant pain, or the misconception that infants and children do not feel pain.
What are the components of a comprehensive pain assessment?
Verbalisation, duration, location, frequency, intensity, type, alleviating factors, physiological and behavioural responses, and referred pain.
What are some physiological indicators of acute pain?
Elevated blood pressure, increased pulse rate, high respiratory rate, pallor, perspiration, and dilated pupils.
What are common behavioral responses indicating pain?
Grimacing, clenched teeth, muscle tension, restlessness, and protection of the injured part.
What is referred pain, and how is it significant in assessment?
Pain perceived at a location other than the site of the painful stimulus, significant for diagnosing underlying conditions.
What are barriers to effective pain assessment and management?
Nurse and midwife beliefs, prescriber practices, patient and family influences, cost, legal concerns, tolerance, physical dependence, and fear of addiction.
What mnemonic can be used for pain assessment and what does it stand for?
SOCRATES: Site, Onset, Character, Radiation, Alleviating factors, Timing, Exacerbating factors, Severity.
What is the significance of the Glasgow Coma Scale (GCS) score in neurological assessment?
The GCS score helps in quantifying the level of consciousness and guiding clinical decision-making for patients with neurological injuries.
How can nurses assess cranial nerve function as part of the neurological assessment?
Through specific tests for each of the 12 cranial nerves, evaluating functions such as smell, vision, eye movement, facial sensation, facial expression, hearing, and swallowing.
What respiratory patterns may indicate brainstem dysfunction or injury?
Abnormal patterns such as Cheyne-Stokes respiration, central neurogenic hyperventilation, apneusis, cluster breathing, ataxic breathing, bradypnoea, and tachypnoea.
Why is monitoring pupillary function important in neurological assessment?
Changes in pupil size, shape, or reactivity can indicate changes in intracranial pressure or damage to neurological pathways.
How does altered level of consciousness affect vital signs?
It can lead to hypertension or hypotension, dysrhythmias, irregular respirations, temperature regulation issues, and hypoxia, signaling neurological deterioration.
What does the AVPU scale stand for, and how is it used?
Alert, Voice responsive, Pain responsive, Unresponsive. It’s a quick way to assess a patient’s level of consciousness.
In what ways do nurses and midwives assess pain in different contexts, such as in nursing and midwifery?
By understanding the subjective nature of pain, using validated assessment tools, considering the physiological and behavioral signs of pain, and accounting for individual differences in pain perception and expression.
What role does the family play in the assessment of pain and neurological status?
Families can provide valuable information about the patient’s normal status, changes in behavior, and responses to pain, especially in patients who cannot communicate effectively.
How can neurological injuries impact a patient’s respiratory patterns, and what are the implications for nursing care?
Neurological injuries can lead to abnormal respiratory patterns, indicating the level of brainstem function or injury. Nurses must monitor these patterns to detect deterioration and manage airway and breathing effectively.
What are examples of central and peripheral methods to assess pain response in unconscious patients?
Central methods include sternal rub and trapezius squeeze; peripheral methods include nail bed pressure and inter-phalangeal joint pressure.
