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Nursing 171 > Physical Assessment: Neurological System > Flashcards

Physical Assessment: Neurological System Flashcards

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1
Q

Neurological System

A 
controls or affects the function of all body systems
-allows interaction with the external world
Basic Functions:
>cognition
>emotion
>memory
>sensation + perception
>regulation of homeostais
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2
Q

Mental Status Assessment

A

-patients appearance
-general behavior
-ability to speak clearly + response to questions
>any alterations could indicate and altered mental state

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3
Q

Areas Assessed with a Mental Status Assessment

A
  • cognitive status
  • orientation
  • memory
  • level of consciousness
  • abstract thinking
  • information processing
  • decision making
  • mood
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4
Q

Level of Consciousness

A
  • arousal: response to stimuli

- orientation: time, place, person

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5
Q

ICU Psychosis

A

psychotic episodes, classically occurring in coronary care patients, occurring within 24 hours after entering the ICU inpatients with no previous history of psychosis; related to sleep deprivation, over-stimulation in ICU and time spent

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6
Q

Cognitive Orientation

A

ability to identify person, place and time accurately

-referred to as levels of awareness

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7
Q

Indicators of Cognitive Orientation

A
  • identifies self + significant others
  • identifies correct day, month, year
  • identifies correct season
  • identifies significant current event
  • identifies where they are
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8
Q

Indicators for recalling recent memory

A

ex:
- what did you eat for breakfast? or
- who brought you to the hospital?

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9
Q

Indicators for recalling remote memory

A

ex: When is your birthday?
- when is your wedding anniversary?
- where were you born?

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10
Q

Indicators for Immediate Memory?

A

ex: ask to repeat a series of numbers
ex: say names of 3 unrelated objects. About 5 minutes later ask the patient to recall the words

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11
Q

Information Processing

A

ability to acquire, organize, and use information

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12
Q

Indicators of ability to process information

A
  • identifies common objects
  • reads + understands a short sentence or paragraph
  • verbalizes a coherent message
  • exhibits organized thought process
  • exhibits logical thought processes
  • explains similarity or dissimilarity between 2 items
  • adds or subtracts several numbers
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13
Q

Mood

A 
refers to a persons enduring and prevailing emotional state
>Common terms to describe mood:
-affect
-labile
-flat affect
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14
Q

Mood: Affect

A

the outward expression of a persons emotional state

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15
Q

Mood: Labile

A

rapid fluctuating or changing mood

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16
Q

Mood: Flat Affect

A
  • lack of emotional response
  • lack of change in facial expression
  • flat voice tones
17
Q

Orientation

A

refers to clients awareness of time, place, and person

“A, A, + O x3”

18
Q

Reflexes

A

automatic responses

19
Q

Deep Tendon Reflexes (DTRs)

A

automatic responses that do not require conscious thought from the brain

20
Q

Deep Tendon Reflexes: Graded Scale

A 
0= no response detected
\+1= diminished response
\+2= response normal
\+3= response somewhat stronger than normal
\+4= response hyperactive with clonus (involuntary contractions that continue after the first contraction is elicited by the hammer)
21
Q

Level of Consciousness (LOC)

A 
includes arousal and orientation
>arousal may range from alert to deeply comatose
-alert
-lethargic
-stupor 
-comatose
AVPU
A=alert
V= verbal stimuli
P= Painful stimuli
U= unresponsive
22
Q

Lethargic

A
  • appears drowsy

- easily drifts off to sleep

23
Q

Stupor

A

requires vigorous stimulation before responding

24
Q

Comatose

A

does not respond to verbal or painful stimuli

25
Q

Mental Status Changes to expect in Older Adults

A
  • severe changes + sudden loss of cognitive function = physical or mental illness
  • information processing speed, abstraction, and mental flexibility may decline with old age
  • ability to divide, switch, or maintain sustained attention may decline with old age
  • long-term memory remains stable while short-term memory exhibits more age-related changes
  • accumulation of practical experience or wisdom, continues until end of life

Nursing 171 (38 decks)

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