NM: Exam Flashcards
Examine: Level of Consciousness
- tests
- levels of consciousness
- Orientation x 3 (person, place, time)
- Response to stimuli: purposeful, non-purposeful or no response; verbal, tactile, simple commands; painful stimuli: pinprick or pinch
Determining LoC:
- –Alertness: Responds appropriately, can OE and look at examiner, respond fully and appropriately to stimuli
- –Lethargy: Patient’s appearance: drowsy, can OE, look at examiner, respond to questions but falls “asleep” easily
- –Obtundation: can OE, look at examiner but responds “slowly” and is “confused”; decreased alertness and interest in environment
- –Stupor: can be “aroused” from sleep ONLY with painful stimuli, verbal response slow or absent, return to “unresponsive state” when stimuli removed; min awareness of self and environment
- –Coma: a state of “unconsciousness”, no arousal at all even with external stimuli, eyes remain closed
- –Unresponsive vigilance (vegetative) state: characterized by sleep/wake cycles, normalization of vegetative functions (RR, HR, BP and digestion) and lack of cognitive responsiveness (aroused but unaware)
- –Persistent vegetative state: state > 1 yr for (TBI) and > 3 months for (anoxic brain injury)
- –Minimal conscious state (MCS): characterized by “severely altered consciousness” with minimal but definite evidence of self or environmental awareness
-Glasgow Coma Scale
Glasgow Coma Scale
—Looks at 3 elements of response: EO, motor and verbal response
—Scoring 3-15:
3-8 = severe brain injury
9-12 = moderate
13-15 = min
Examine: Cognitive Fxn (Memory)
- –Immediate recall: name 3 items previously presented after a brief interval
- –Recent memory (short term): recall of recent events
- –Remote memory (long term): recall past events
Examine: Cognitive Fxn (Attention)
- –Length of attention span: digit span retention test (ex: ability to recall 7 numbers in order of which it was presented)
- –Sustained attention: ability to tend to task without re-direction
- –Divided attention: ability to shift attention from one task to another; assess ability of “dual-tasking” and perserveration (mental inertia): getting stuck on a task
- –Focused attention: ability to stay on task in presence of distractors; assess impact of environment vs internal distractors
- –Ability to follow commands: 1 or 2 step commands or multi-level commands
Examine: Cognitive Fxn (Emotional Response/Behavior)
- –Safety, judgement: impulsivity and lack of inhibition
- –Affect, mood: irritability, agitation, depression and withdrawal
Higher-level Cognitive abilities:
- –Judgement, problem solving, abstract reasoning
- –Fund of general knowledge: “Ability to learn new information”, generalize learning to new situations, Calculation: “serial 7 test” (count backwards from 100 by 7s), Sequencing: ability to order components of cognitive or functional tasks; assess if cueing is necessary, frequency of cues
Mini-Mental State Examination (MMSE)
—Brief screening test for “cognitive dysfunction”
—Includes items for: orientation, registration, attention and calculation, recall and language
—Max score 30
21-24 (mild cognitive impairment)
16-20 (mod)
<15 (severe)
Rancho Los Amigos Level of Cognitive Function (LOCF)
—Assess cognitive recovery from “TBI”
—Eight levels:
Level 1: No response
Level 2-3: decreased response
Level 4-6: confused
Level 7-8: appropriate (automatic, purposeful)
—Delineates emerging behaviors; patients may plateau at any level
Examine:
Speech
(Determine type of Aphasia )
Non-fluent/Expressive/Broca’s Aphasia =
- –Lesion: 3rd frontal convolution of the Left hemisphere
- –A central language disorder in which speech is typically awkward, restricted, interrupted and produced with effort
Fluent/Wernicke’s/Receptive Aphasia =
- –A central language disorder in which spontaneous speech is “preserved” and flows smoothly, while “auditory comprehension” is impaired
- –Lesion: posterior first temporal gyrus of the L hemisphere
Verbal Apraxia / Dysarthria
—impairment of speech production resulting from damage to central or peripheral NS; causes weakness, paralysis or incoordination of motor-speech system (respiration, articulation, phonation, and movements of jaw and tongue)
Global Aphasia
- –Severe Aphasia
- –Examine for marked impairments in comprehension and production of language
Examine: Speech
Non-verbal communication
- –Examine ability to read and write
- –Use of gestures, symbols and pictographs
Examine: Vital Signs
- –HR increases in DIRECT proportion to intensity of exercise (SBP: increases, DBP: remains the same or decreases slightly)
- –With increasing intra-cranial pressure, examine for late HR and BP changes
- –Temperature : High temperature may indicate infection, damage to the hypothalamus or brainstem
Examine: Vital Signs
Types of Respiration
Cheyne-stokes Respiration
—a period of apnea lasting 10-60 seconds followed by gradually increasing depth and frequency of respirations; accompanies depression of “frontal lobe” and “diencephalic” dysfunction
Hyperventilation: increased rate and depth of respiration; accompanies dysfunction of lower mid-brain and pons
Apneustic breathing: Abnormal respiration marked by prolonged inspiration; accompanies damage to the UPPER pons
Examine for CNS Infection or Meningeal Irritation
Signs are GLOBAL not focal
—Kernig’s Sign: patient is positioned in supine, flex hip/knee fully to chest and then extend knee.
(+): causes pain and increased resistance to “extending knee” d/t spasm of hamstring; when bilateral suggests “meningeal irritation”
—Brudzinki’s sign: patient positioned in supine, flex neck to chest
(Pos): causes flexion of hips and knees (drawing up), suggest meningeal irritation
—Slowed mentation function: persistent H/A, worse in head-down position, may progress to delirium, lethargy and coma
—Generalized weakness
Examine: Reflexes (DTRs)
DTR: normally occurring reflexes in response to stretch of muscle Common reflexes: jaw, trigeminal (CNV), biceps (C5-6), triceps (C7-8), brachioradialis (C5-6), HS (L5-S3), quads L2-4), Achilles (S1-2) Scoring: 0 : absent 1+ : decreased response 2+ : normal response 3+ : exaggerated 4+ : hyperactive
Examine: Reflexes (Superficial Cutaneous)
normally occurring reflexes in response to “noxious stimulus” (light scratch) applied to skin
Plantar Reflex (S1-2, tibial n) - stroking of lateral sole of foot from calcaneus to base of 5th met and medially acroos met heads produces toe PF Positive Babinsky Response: great toe DF and ABD of lesser toes; seen in patinets with corticospinal lesions
Abdominal Reflexes: lateral to medial scratching of skin (towards umbilicus) in each of four quadrants produces deviation of the umbilicus toward the stimulus ; loss = sign of corticospinal reflexes
Cremasteric Reflex (L1-2) : stroking of skin of the proximal and medial thigh produces elevation of the testicle; absent in SCI and coriticospinal lesions
Examine: Reflexes (primitive/spinal reflexes)
*present developmentally in normal infants and in some pts with brain injury
Flexor Withdrawal : noxious pinprick to sole of foot
normal response: toe EXT, foot DF, LE FLX
Crossed Extension Reflex: noxious stim to sole of foot
normal response: LE FLX and contralat LE EXT/ADD
Traction: stretch stim from grasping the forearm and pulling
normal response: UE FLX
Grasp: maintained pressure to palm of hand (PALMAR GRASP) or ball of foot (PLANTAR GRASP)
normal response: maintained FLX of fingers or toes
