the final Flashcards
-paresis:
-plegia:
aphagia:
aphasia:
apraxia:
ataxia:
dysarthria:
dyskinesia:
dysphagia:
hippus:
nystagmus:
paresthesia:
pronator drift:
syncope:
tinnitus:
vertigo:
-paresis: mild to moderate degree of muscle weakness
-plegia: paralysis; stroke; cessation of motion
Aphagia: severe condition characterized by the inability to swallow, leads to persistent drooling and the inability to eat or drink
Aphasia: loss of ability to understand or express speech, caused by brain damage.
Apraxia: Inability to perform learned movements despite having desire and physical ability to perform them, the the inability to carry out learned, sequential movements on command
Ataxia: loss of voluntary muscle control
Dysarthria: lack of coordination in articulating speech
Dyskinesia: An impairment of the ability to execute voluntary movements
Dysphagia: Difficulty swallowing
Dysphasia: A language disorder that affects the ability to produce and understand spoken language
Hippus: rare condition that causes the pupil to rhythmically dilate and contract in a spasmodic manner (restless pupil mobility)
Nystagmus: a condition that causes involuntary, rapid, and rhythmic eye movements
Paresthesia: absent or ↓ low sensation, hypersensation, one of the 6 Ps of arterial ischemia (numbness or tingling) in the toes or feet may result from nerve tissue ischemia,
Pronator Drift: a neurological sign that indicates weakness in the upper limbs (when their arm turns inward and downward while they are holding their arms outstretched)
Syncope: brief lapse in consciousness caused by transient cerebral hypoxia. Usually preceded by a sensation of light-headedness
Tinnitus: A subjective noise sensation, often described as ringing, heard in one or both ears
Vertigo: sensation of dizziness/spinning
macular degeneration & corneal degeneration lead to
impaired vision
decreased nerve conduction leads to…
slowed reflexes; slower thought processing
decreased cerebral flow and metabolism lead to…
altered balance, vertigo, syncope
decreased muscle build leads to
decreased strength and agility
degenerative changes and decreased number of sensory receptors lead to…
decreased senses (taste, touch, pain, temperature)
what are some examples of noxious stimuli to assess motor function?
Trapezius squeeze
Sternal rub (rubbing the sternum firmly with a knuckle)
Supraorbital pressure (pressing on the supraorbital ridge above the eye)
Nail bed pressure
Which tool is appropriate for quickly screening if a patient may be having a stroke
BEFAST
Which tool is appropriate for assessing progression of symptoms during & after stroke?
NIHSS
Glasgow Coma Scale: Eyes
4: Spontaneous
3: To speech
2: To pain
1: No response
Glasgow Coma Scale: Speech
5: Oriented
4: Confused
3: Inappropriate words
2: Incomprehensible sounds
1: No response
Glasgow Coma Scale: Motor
6: Obeys commands
5: Moves to localized pain
4: Flexion withdrawal from pain
3: Abnormal flexion (decorticate)
2: Abnormal extension (decerebrate)
1: No response
CAM assesses for:
Mini-Cog assesses for:
Age-Related Risks
CAM = delirum
(Diagnosis of delirium by CAM requires presence of Features 1 AND 2 and either 3 OR 4)
Mini-Cog = dementia
(state three words, pt draw clock, repeat words)
Fulmer-SPICES
olfactory
optic
oculomotor
trochlear
I:
F: sense of smell.
A: have pt identify smells
II:
F: visual acuity
A: snellen chart/ask pt to read printed
material
III:
F: inward, up and outward. Pupil constriction & dilation. Opening the eye
A: assess 6 directions of gaze. measure pupillary reaction to light reflex and accommodation.
IV:
F: Downward, inward eye movements
A: Assess six directions of gaze.
trigeminal
abducens
facial
vestibulocochlear
V:
F: Sensory nerve to skin of face. Nerve to muscles of jaw
A: Assess corneal reflex. Measure sensation of light pain & touch across skin of face. Palpate temples as pt clenches teeth.
VI:
F: : Lateral movement of eyeballs
A: assess 6 directions of gaze.
VII:
F: Taste + Facial expression
A: identify taste, make faces
VIII:
F: hearing
A: assess ability to hear whispered words bilaterality
glossopharyngeal
vagus
spinal accessory
hypoglossal
IX:
F: Taste + ability to swallow
A: taste on back of tongue + gag reflex
X:
F: sensation of pharynx, movement of vocal chords. PNS innervation of heart, lungs, most of GI tract
A: say “ah”, hoarseness, HR, peristalsis,
XI:
F: Movement of head and shoulders
A: shrug and turn head
XII:
F: position of tongue
A: Ask patient to stick out tongue to midline and move it from side to side
How frequently must orders for medical restraints be renewed?
q24 hrs
In regards to restrains, what should be done every 12 hours
At minimum, RN assessment and documentation of attempted alternatives
and necessity must be performed
With regards to restraints, what should be done every 2 hours?
RN monitoring (including removal, skin check, CSM assessment, ROM, toileting, nourishment) must be performed q2hr for medical restraints
Alternatives to medical restraints
Reorientation, Education, Distraction, Cover line/tube so it cannot be seen, Fall prevention strategies such as bed alarms, 1:1 sitter or family stay with patient if possible
what is the ejection fraction
the % of end-diastolic blood volume that is ejected during systole, can be measured with an echocardiogram, provides info about the function of the left ventricle during systole
heaves
sustained lifts of the chest wall in the precordial area that you can see or palpate may be caused by left ventricular hypertrophy
MAP calculation
(SBP) + (2 x DBP) / 3
PMI (apical pulse)
the pulsation of the apex of the heart; lies medial to midclavicular line in the 4th or 5th ICS
if PMI is below the 5th ICS and left of the midclavicular line…heart may be enlarged
