RESPONSE TO ALTERED SENSORY-PERCEPTUAL FUNCTION Flashcards
What are the 2 assessment?
Subjective Data
➔ Important Health Information
➔ Functional Health Patterns
Objective Data
➔ Physical Examination
➔ Diagnostic Studies
What are the 6 Physical Examination?
- Mental Status
- Cranial Nerve Function
- Motor function
- Sensory function
- Cerebellar function
- Reflexes
Components Of Mental Status
Keyword: GCM
General Appearance & Behavior
➔ It Includes Level Of Consciousness (Awake,
Asleep, Comatose), Motor Activity, Body
Posture, Dress & Hygiene, Facial Expression &
Speech
Cognition
➔ Note Orientation to Time, Place, Person &
Situation. Memory, General Knowledge, Insight,
Judgment, Problem Solving & Calculation
Mood & Affect
➔ Note Any Agitation, Anger, Depression, Or
Euphoria & Appropriateness of These States.
12 cranial nerves and their function
I. Olfactory - smell
II. Optic - from retina of eyes (vision)
III. Oculomotor - 4 eyes movement muscles & levator
palpebrae muscle
Parasympathetic: smooth
muscle in eyeball
IV. Trochlear - one eye
movement muscle, the
superior oblique muscle
V. Trigeminal - from forehead, eye, superior nasal cavity
Maxillary branch - from inferior nasal cavity, face, upper teeth, mucosa of superior mouth
Mandibular branch - from surfaces of jaw, lower teeth, mucosa of lower mouth, & anterior
tongue
Motor: to muscles of
mastication
VI. Abducens - lateral rectus
of the eye
VII. Facial - facial muscles of
expression & cheek muscle
Sensory: taste from anterior
two thirds of tongue
VIII. Vestibulocochlear
Vestibular Branch
Cochlear Branch - equilibrium
sensory organ, the
vestibular apparatus
Sensory: from auditory
sensory organ, the cochlea
IX. Glossopharyngeal - pharynx &
posterior tongue, including
taste
Motor: to superior
pharyngeal muscle
X. Vagus - from much of
viscera of thorax &
abdomen
Motor: to larynx & middle
& inferior pharyngeal
muscles
Parasympathetic: heart,
lungs, most of digestive
system
XI. Accessory -sternocleidomastoid &
trapezius muscles
XII. Hypoglossal - muscles of
tongue
Includes assessment of strength, tone,
coordination, & balance
MOTOR FUNCTION
4 motor functions
- Strength & symmetry
- Tone
- Cerebellar Function (Coordination & Balance)
- Coordination & Cerebellar
What motor function is this?
“Ask the patient to push & pull against resistance
of your arm as it opposes flexion & extension of
the patient’s muscle”
Strength & Symmetry
What motor function is this?
“Passively moving the limbs thru their rom, there
should be a slight resistance to these movements”
Tone
What motor function is this?
Observe the patient’s stature (posture while
standing) & gait
➔ Romberg’s tests
Cerebellar Function
What motor function is this?
Finger to nose test & heel to shin test
Coordination & Cerebellar
Terms Associated to Motor Function
- Mild weakness of the arm is demonstrated by
downward drifting of the arm or pronation of
the palm - Flaccidity
- Spasticity
- Spasm of muscles
- Slow, writhing, involuntary movements of
extremities - Involuntary, purposeless, rapid motions
- Impairment of muscle tone
- Pronator drift
- Hypotonia
- Hypertonia
- Myoclonus
- Athetosis
- Chorea
- Dystonia
3 Test for sensory function
Keyword: TVP
- Touch, pain & temperature
- Vibration sense
- Position sense
Other word for PROPRIOCEPTION
Position sense
Involuntary contractions of muscles
0
1+
2+
3+
4+
reflexes
0 - no response
1+ diminished
2+ normal
3+ increased (can be normal)
4+ hyperactive
7 Common Assessment Abnormalities
- Mental Status
- Speech
- Eyes
- Sensory System
- Reflexes
- Motor System
- Spinal Cord
- Cranial Nerves
Enumerate Glascow Coma Scale (GCS) & NIHSS Stroke Scale
NIHSS Stroke:
0 - No stroke
0-4 - Minor stroke
5-15 - Moderate stroke
16-20 - Moderate to severe stroke
21-42 - Severe stroke
GCS:
Eye opening response - 4
Best Verbal response - 5
Best Motor response - 6
Total score:
Best response = 15
Comatose client = 8 or less
Totally unresponsive = 3
Full Outline of Unresponsiveness (Four) Score
Minimum score:
Maximum score:
The lower the score,
Minimum score: 0
Maximum score: 16
The lower the score, THE GREATER THE COMA
DIAGNOSTIC STUDIES (Identify what department belongs to):
- CSF is aspirated by needle
insertion in L3-4 or L4-5
interspace to assess many CNS diseases. - Simple x-ray of skull & spinal column is done to detect fractures, bone erosion, calcifications, abnormal vascularity.
- Serial X-ray visualization of intracranial & extracranial
blood vessels is performed to detect vascular lesions &
tumors of brain. Contrast
medium is used. - Computer-assisted x-ray of multiple cross sections of body parts to detect problems such as hemorrhage, tumor, cyst, edema, infarction, brain
atrophy, & other abnormalities. Contrast media may be used to
enhance visualization of brain structures. - Imaging of brain, spinal cord & spinal canal by means of magnetic energy.
- Has greater contrast in
images of soft tissue structures than CT scan. - Uses differential signal
characteristics of flowing blood to evaluate extracranial &
intracranial blood vessels. - Measures metabolic activity of brain to assess cell death or damage.
- A method of scanning similar to PET, but it uses more stable substances & different detectors.
- X-ray of spinal cord & vertebral column after injection of contrast medium into subarachnoid space.
- Electrical activity of brain is recorded by scalp electrodes to evaluate seizure disorders, cerebral disease, CNS effects of
systemic diseases, brain death. - Electrical activity associated with nerve & skeletal muscle is recorded by insertion of needle
electrodes to detect muscle & peripheral nerve disease. - Combined ultrasound & pulsed doppler technology
- Same technology as carotid duplex, but evaluates blood
flow velocities of the
intracranial blood vessels.
- Lumbar puncture (CSF Analysis)
- Skull & Spine X-rays
- Cerebral Angiography
- CT scan (Computed Tomography)
- MRI (Magnetic Resonance Imaging)
- MRA (Magnetic Resonance Angiography)
- PET Scan (Positron Emission Tomography)
- SPECT (Single-photon Emission Computed Tomography)
- Myelogram
- EEG (Electroencephalography)
- EMG (Electromyography) & Nerve Conduction Studies
- Carotid duplex studies
- Transcranial doppler
2-9 = RADIOLOGY
10-11 = ELECTROGRAPHIC STUDIES
12-13 = ULTRASOUND
5 Neurologic Alterations
Keyword: ITAST
- Increase Intracranial Pressure
- Traumatic Head Injury
- Acute Ischemic Stroke
- Seizure Disorders & Epilepsy
- Traumatic Spinal Cord Injury
The hydrostatic force measured in the brain CSF
compartment
Intracranial pressure
3 components that maintains the ICP?
Keyword: BBC
Brain tissue
Blood
CSF
Normal ICP ranges from __ to ___mmHg
5 -15 mmHg
ICP = _____ + ______+ _____
Keyword: C + B + C
ICP = Pcerebrum + Pblood + PcsF
