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nrsg 202 > Week 10 - Advanced Neurological Assessment and Care > Flashcards

Week 10 - Advanced Neurological Assessment and Care Flashcards

1
Q

What are 3 major considerations in the extent of the neurological examination?

A

clients:

  • complaints
  • physical condition
  • willingness to participate
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2
Q

what does a neurological assessment include?

A
  • mental status
  • LOC
  • cranial nerves
  • reflexes
  • motor function
  • sensory function
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3
Q

What is included in the mental status ?

A
  • language
  • orientation
  • memory
  • attention span/ calculation
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4
Q

What does a mental status reveal?

A
  • general cerebral function

- intellectual/ emotional functions

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5
Q

What is included in the LOC in regards to the neurological assessment?

A
  • state of alertness

- GCS

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6
Q

what is cranial nerve II? describe it

A
  • optic
  • eye
  • sensory
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7
Q

what is cranial nerve III? describe it

A
  • oculomotor

- all eye muscles except those supplied by IV and VI

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8
Q

what is cranial nerve IV? describe it

A
  • trochlear
  • motor
  • external rectus muscle
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9
Q

what is cranial nerve VI? describe it

A
  • abducent
  • motor
  • external rectus muscle
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10
Q

what is cranial nerve IX? describe it

A

glossopharyngeal

  1. motor
    - pharyngeal musculature
  2. sensory
    - posterior part of tongue, tonsils, pharynx
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11
Q

what is cranial nerve X? describe it

A

vagus

  1. motor
    - heart, lungs, bronchi, GI tract
  2. sensory
    - heart, lungs, trachea, larynx, pharynx, GI tract, external ear
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12
Q

what is cranial nerve XII? describe it

A

accessory

  • motor
  • sternocleidomastoid and trapezius muscles
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13
Q

describe reflexes

A
  • automatic response of body to a stimulus

- not voluntary or conscious

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14
Q

what is used to test reflexes?

A

percussion hammer

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15
Q

reflexes compare what?

A

one side of the body to the other

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16
Q

in regards to reflex tests where on the body would you have one ?

A
  • biceps
  • triceps
  • brachioradialis
  • patellar
  • achilles
  • plantar
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17
Q

What are the different types of motor function?

A
  • gross motor

- fine motor

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18
Q

What are proprioceptors?

A

person is aware of where their body is

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19
Q

describe sensory ataxia

A

person fine with eyes open but once they’re closed they loose balance

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20
Q

describe cerebellar ataxia

A

person has bad balance or gait when walking

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21
Q

what is hyperesthesia?

A

increased sensitivity to any of your senses

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22
Q

what is paresthesia?

A

burning prickling sensation usually felt in hands, legs, feet

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23
Q

What are dermatomes?

A

areas on skin that are innervated primarily by a single spinal cord segment

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24
Q

What are the different categories of dermatomes?

A
  • cervical
  • thoracic
  • lumbar
  • sacrum
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25
Q

How many dermatomes are there in the cervical section?

A

7

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26
Q

How many dermatomes are there in the thoracic section?

A

12

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27
Q

How many dermatomes are there in the lumbar section?

A

5

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28
Q

How many dermatomes are there in the sacrum section?

A

5

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29
Q

When do strokes occur?

A

when there is schema to part of the brain or hemorrhage into the brain that results in death of brain cells

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30
Q

describe the national institute of health stroke score (NIHSS) test

A
  • part of the stroke/ TIA protocol

- quantifies stroke severity based on weighted evaluation findings

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31
Q

describe the Toronto Bedside Swallowing Screening Test (TOR-BSST) test

A

swallowing assessment that trained nurses perform to assess if client can tolerate a diet

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32
Q

in regards to a stroke, what would a nurse see if the right side of the brain was affected?

A
  • paralyzed left side of body
  • speech/ language deficits
  • slow, cautious behavioural style
  • memory deficits
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33
Q

in regards to a stroke, what would a nurse see if the left side of the brain was affected?

A
  • paralyzed right side of body
  • special perceptual deficits
  • quick impulsive behavioural style
  • memory deficits
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34
Q

What are the different tools used for stroke assessments?

A
  • glasgow coma scale (GCS)
  • national institute of health stroke scale (NIHSS)
  • Canadian neurological scale
  • TOR-BSST
  • SST
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35
Q

What is a seizure?

A

sudden onset of excessive transient uncontrolled electrical discharges of the neurons in one or more areas of the brain interrupting normal function

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36
Q

what can seizures accompany?

A
  • other disorders
  • symptom of underlying illness
  • occur spontaneously without apparent cause
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37
Q

What is a metabolic related seizure?

A

seizure resulting from systemic/ metabolic disturbances are not considered epilepsy if they cease when underlying condition is treated

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38
Q

in regards to metabolic related seizures what do they possibly originate from when talking about metabolic disturbances?

A
  • acidosis
  • electrolyte imbalances
  • hypoglycemia
  • hypoxemia
  • alcohol or barbiturate withdrawal
  • dehydration/ water intoxication
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39
Q

in regards to extracranial related seizures what do they possibly originate from when talking about extra cranial disorders?

A
  • heart
  • hypertension
  • lung
  • kidneys
  • liver
  • DM
  • septicemia
40
Q

describe epilepsy

A
  • person has spontaneously recurring seizures that occur more than 24hrs apart
  • caused by underlying chronic condition
41
Q

seizures are divided into 3 major categories, what are they?

A
  • generalized onset
  • partial onset
  • unknown onset
42
Q

What are the seizure phases? describe them

A
  1. prodromal
    - precedes seizure with signs of activity
  2. aural phase
    - sensory warning
  3. ictal phase
    - seizure
  4. postical
    - rest and recovery
43
Q

generalized seizures are characterized by what?

A
  • bilateral synchronous epileptic discharges in brain from seizure onset
  • affects whole brain
  • no warning/ aura
  • loss of consciousness for seconds - minutes
44
Q

what are the different types of generalized seizures?

A
  • tonic clonic
  • typical absence seizure
  • atypical absence seizure
  • myoclonic
  • atonic
  • tonic
  • clonic
45
Q

describe a tonic clonic seizure

A
  • loss of consciousness/ falling
  • body stiffens c jerking of extremities
  • cyanosis
  • tongue/ cheek biting
  • excessive salivation
46
Q

describe the postictal phase for tonic clonic seizures

A
  • muscle soreness
  • fatigue
  • patient may sleep for hours
  • may not feel normal for days
  • no memory of seizure
47
Q

describe a typical absence seizure

A
  • occurs only in children rarely in adolescence

- may cease/ develop into another type

48
Q

what are the characteristics of typical absence seizure

A
  • staring spell for few seconds
  • brief LOS
  • may occur up to 100times/ day if untreated
  • ECG pattern unique
  • precipitated by hyperventilation/ flashing lights
49
Q

what are the characteristics of atypical absence seizure

A
  • starring spell
  • brief warnings
  • peculiar behaviour during seizure
  • confusion after
  • ECG atypical spike and wave patterns
50
Q

what are the characteristics of a myoclonic seizure

A
  • sudden/ eccessive jerk of body/ extremities
  • forceful enough to cause fall
  • brief/ may occur in clusters
51
Q

what are the characteristics of atonic seizures?

A
  • involves tonic episode
  • person falls
  • consciousness returns by tie person hits ground/ can resume normal activity
  • great risk for head injury
52
Q

describe a tonic seizure

A

involve sudden onset of sustained increased tone in extensor muscle

53
Q

describe clonic seizures

A
  • begin with LOS and sudden loss of muscle tone

- followed by limb jerking that may/ may not be symmetrical

54
Q

describe focal (partial) seizures

A
  • electrical discharges from one area of brain resulting in unilateral manifestations
  • caused by focal irritations
  • begin in specific region of cortex
55
Q

describe a focal aware seizure (simple partial seizure)

A
  • no LOC
  • rarely lasts longer than 1min
  • may involve motor, sensory or autonomic phenomena
56
Q

what can focal impaired awareness seizures involve?

A
  • behavioural
  • emotional
  • affective
  • sensory
  • cognitive function
57
Q

what are the characteristics of a focal impaired awareness seizures

A
  • alteration in LOC
  • lasts longer than 1 min
  • followed by period of postictal confusion
  • lip smacking
  • psychosensory symptoms
58
Q

what psychosensory symptoms can occur during a focal impaired awareness seizure

A
  • disorientation of visual, auditory sensations
  • alterations in memory/ thought process
  • alterations in sexual function
59
Q

describe status epilepticus

A
  • state of constant seizure
  • seizures recur in rapid succession without return to consciousness between seizures
  • causes brain to use more energy than its supplied
60
Q

describe tonic-clonic status epilepticus

A
  • most dangerous

- cause ventilatory insufficiency, hypoxemia, arrhythmias

61
Q

What are complications that can result from seizures?

A
  • severe injury/ death
  • social stigma
  • discrimination in employment/ education
  • driving sanctions
  • depression
62
Q

what are diagnostics and treatments for seizures?

A
  • seizure history
  • physical exam
  • EEG
  • blood work
  • CT
  • MRI
  • medications
  • surgery
  • counselling
  • special diet (keto)
63
Q

What are some triggers for seizures?

A
  • stress
  • excessive excitement/ fluid intake
  • extremely low blood sugar
  • sunlight
  • heat
  • humidity
  • flickering lights
  • skipping meals
  • illness
  • lack of sleep
  • withdrawal from drugs/ alcohol
  • missed meds
64
Q

prior to a seizure what can a nurse do to ensure patient safety?

A
  • place padding Lining in bed

- ensure safety check has been completed

65
Q

What should the nurse do while seizure is occurring?

A
  • ensure safe area/ patent airway
  • stay with client until seizure passes
  • turn patient on side
  • apply oxygen
  • suction prn
  • assist with ventilation
66
Q

What should the nurse NOT do while seizure is occurring?

A
  • restrain patient

- insert anything into patients mouth

67
Q

what does the nurse need to continue to monitor in a patient who had a seizure?

A
  • vital signs
  • LOC
  • GCS
68
Q

when documenting post seizure what do you need to include ?

A
  • events preceding
  • when the seizure occurred
  • length of seizure for each phase
  • what occurred each phase
69
Q

when using oral suctioning for seizures you use suction to what?

A
  • remove secretions that obstruct airway
  • ventilation
  • get secretions for diagnostic purposes
70
Q

What supplies is needed for suctioning?

A
  • clean hands
  • gloves
  • yankauer
  • suction tubing and canister
71
Q

for suctioning as adult the suction should be set at what?

A

100-150

72
Q

What is the primary drug leading to health-related problems in North America that is the most widely consumed substance?

A

alcohol

73
Q

does alcohol cross the blood brain barrier? What does this cause?

A

yes, when patient withdrawals from alcohol neurochemicals changes occur

74
Q

What are some medical conditions associated with unhealthy alcohol use ?

A
  • hypertension
  • CV disease
  • liver disease
  • pancreatitis
  • gastritis
  • esophagitis
  • done marrow suppression
  • chronic infectious diseases
  • cancer
  • psychiatric disorders
75
Q

What are some challenges when people are admitted with AWS?

A
  • hypovolemia/ dehydration
  • malnutrition
  • electrolyte imbalances
76
Q

How does excessive alcohol impact sleep?

A

body doesn’t go into REM sleep

77
Q

in regards to challenges with people when they are admitted with AWS describe hypovolemia/ dehydration

A
  • alcohol diuretic
  • nausea/ vomiting
  • poor appetite
  • not drinking enough water
  • diaphoresis
78
Q

in regards to challenges with people when they are admitted with AWS describe malnutrition

A
  1. alcohol causes gastritis and pancreatitis
    - reduces food intake/ absorption
  2. not eating nutritious diet when drinking
79
Q

in regards to challenges with people when they are admitted with AWS describe electrolyte imbalances

A
  • malnourished have low levels of many electrolytes

- malnourished clients come to hospital at risk of referring syndrome

80
Q

what can thiamine (B1) deficiency cause in alcoholics?

A
  • beriberi

- wernicke’s encephalopathy

81
Q

what causes beriberi

A

diet deficient in thiamine

82
Q

what are the 2 types of beriberi? describe them

A
  1. dry beriberi
    - involves development of peripheral neuropathy
  2. wet beriberi
    - involves progression to cardiomegaly, HF, peripheral edema
83
Q

describe Wernicke’s encaphalopathy

A
  • related to dry beriberi
  • acute syndrome requires urgent care
  • damage to nerves/ blood vessels in brain
  • can lead to irreversible brain damage if not treated
84
Q

Why do alcoholics have vitamins deficiencies?

A
  • poor diet
  • unable to absorb vitamins
  • liver unable to store vitamins in cirrhosis
85
Q

What are manifestations of wenicke’s encephalopathy?

A
  • ataxia
  • nystagmus
  • confusion
86
Q

what are signs and symptoms of Korsakoff’s psychosis?

A
  • inability to form new memories
  • back of insight into condition
  • patient makes up stories
87
Q

what happens when someone has minor withdrawals?

A
  • insomnia
  • tremors
  • mid anxiety
  • GI upset
  • headache
  • sweating
  • palpitations
  • starts 6hrs after last drink
  • resolves after 12-48hrs
88
Q

what happens when someone has major withdrawals?

A
  • dysrhythmias
  • more autonomic hyperactivity
  • seizures
  • hallucinations
  • start around 6hrs
  • resolves after 72hrs
89
Q

What are the stages of alcohol withdrawal (AWS)

A
  1. 6-12hrs
    - minor withdrawal symptoms
  2. 12-14hrs
    - hallucinations
  3. 24-48hrs
    - seizures
  4. 48-72hrs
    - delirium
90
Q

what are the precursors to withdrawal seizures?

A
  • long history of alcohol use

- +40yrs old

91
Q

What are some risk factors for delirium tremens?

A
  • chronic alcohol use
  • history of previous DT
  • +30yrs old
  • severe withdrawal symptoms at presentation
  • prior detox
92
Q

in regards to the kindling phenomenon what happens with each episode of alcohol use and alcohol withdrawal even if mild ?

A

brain becomes more:

  • excitable
  • sensitive to effects of alcohol withdrawal
93
Q

in regards to the kindling phenomenon what happens with each episode of alcohol withdrawal?

A
  • clinical manifestations become more severe

- people become increasingly likely to experience seizure/ DT

94
Q

what 2 drugs are most commonly used for alcohol withdrawal syndrome in regards to a CIWA ?

A
  • diazepam

- lorazepam

95
Q

if AWS is suspected, what common tests are used?

A
  • CBC/ electrolytes
  • liver function test
  • total protein/ albumin
  • lipase
  • glucose
  • ECG

nrsg 202 (11 decks)

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