Week 10 - Advanced Neurological Assessment and Care Flashcards
What are 3 major considerations in the extent of the neurological examination?
clients:
- complaints
- physical condition
- willingness to participate
what does a neurological assessment include?
- mental status
- LOC
- cranial nerves
- reflexes
- motor function
- sensory function
What is included in the mental status ?
- language
- orientation
- memory
- attention span/ calculation
What does a mental status reveal?
- general cerebral function
- intellectual/ emotional functions
What is included in the LOC in regards to the neurological assessment?
- state of alertness
- GCS
what is cranial nerve II? describe it
- optic
- eye
- sensory
what is cranial nerve III? describe it
- oculomotor
- all eye muscles except those supplied by IV and VI
what is cranial nerve IV? describe it
- trochlear
- motor
- external rectus muscle
what is cranial nerve VI? describe it
- abducent
- motor
- external rectus muscle
what is cranial nerve IX? describe it
glossopharyngeal
- motor
- pharyngeal musculature - sensory
- posterior part of tongue, tonsils, pharynx
what is cranial nerve X? describe it
vagus
- motor
- heart, lungs, bronchi, GI tract - sensory
- heart, lungs, trachea, larynx, pharynx, GI tract, external ear
what is cranial nerve XII? describe it
accessory
- motor
- sternocleidomastoid and trapezius muscles
describe reflexes
- automatic response of body to a stimulus
- not voluntary or conscious
what is used to test reflexes?
percussion hammer
reflexes compare what?
one side of the body to the other
in regards to reflex tests where on the body would you have one ?
- biceps
- triceps
- brachioradialis
- patellar
- achilles
- plantar
What are the different types of motor function?
- gross motor
- fine motor
What are proprioceptors?
person is aware of where their body is
describe sensory ataxia
person fine with eyes open but once they’re closed they loose balance
describe cerebellar ataxia
person has bad balance or gait when walking
what is hyperesthesia?
increased sensitivity to any of your senses
what is paresthesia?
burning prickling sensation usually felt in hands, legs, feet
What are dermatomes?
areas on skin that are innervated primarily by a single spinal cord segment
What are the different categories of dermatomes?
- cervical
- thoracic
- lumbar
- sacrum
How many dermatomes are there in the cervical section?
7
How many dermatomes are there in the thoracic section?
12
How many dermatomes are there in the lumbar section?
5
How many dermatomes are there in the sacrum section?
5
When do strokes occur?
when there is schema to part of the brain or hemorrhage into the brain that results in death of brain cells
describe the national institute of health stroke score (NIHSS) test
- part of the stroke/ TIA protocol
- quantifies stroke severity based on weighted evaluation findings
describe the Toronto Bedside Swallowing Screening Test (TOR-BSST) test
swallowing assessment that trained nurses perform to assess if client can tolerate a diet
in regards to a stroke, what would a nurse see if the right side of the brain was affected?
- paralyzed left side of body
- speech/ language deficits
- slow, cautious behavioural style
- memory deficits
in regards to a stroke, what would a nurse see if the left side of the brain was affected?
- paralyzed right side of body
- special perceptual deficits
- quick impulsive behavioural style
- memory deficits
What are the different tools used for stroke assessments?
- glasgow coma scale (GCS)
- national institute of health stroke scale (NIHSS)
- Canadian neurological scale
- TOR-BSST
- SST
What is a seizure?
sudden onset of excessive transient uncontrolled electrical discharges of the neurons in one or more areas of the brain interrupting normal function
what can seizures accompany?
- other disorders
- symptom of underlying illness
- occur spontaneously without apparent cause
What is a metabolic related seizure?
seizure resulting from systemic/ metabolic disturbances are not considered epilepsy if they cease when underlying condition is treated
in regards to metabolic related seizures what do they possibly originate from when talking about metabolic disturbances?
- acidosis
- electrolyte imbalances
- hypoglycemia
- hypoxemia
- alcohol or barbiturate withdrawal
- dehydration/ water intoxication
in regards to extracranial related seizures what do they possibly originate from when talking about extra cranial disorders?
- heart
- hypertension
- lung
- kidneys
- liver
- DM
- septicemia
describe epilepsy
- person has spontaneously recurring seizures that occur more than 24hrs apart
- caused by underlying chronic condition
seizures are divided into 3 major categories, what are they?
- generalized onset
- partial onset
- unknown onset
What are the seizure phases? describe them
- prodromal
- precedes seizure with signs of activity - aural phase
- sensory warning - ictal phase
- seizure - postical
- rest and recovery
generalized seizures are characterized by what?
- bilateral synchronous epileptic discharges in brain from seizure onset
- affects whole brain
- no warning/ aura
- loss of consciousness for seconds - minutes
what are the different types of generalized seizures?
- tonic clonic
- typical absence seizure
- atypical absence seizure
- myoclonic
- atonic
- tonic
- clonic
describe a tonic clonic seizure
- loss of consciousness/ falling
- body stiffens c jerking of extremities
- cyanosis
- tongue/ cheek biting
- excessive salivation
describe the postictal phase for tonic clonic seizures
- muscle soreness
- fatigue
- patient may sleep for hours
- may not feel normal for days
- no memory of seizure
describe a typical absence seizure
- occurs only in children rarely in adolescence
- may cease/ develop into another type
what are the characteristics of typical absence seizure
- staring spell for few seconds
- brief LOS
- may occur up to 100times/ day if untreated
- ECG pattern unique
- precipitated by hyperventilation/ flashing lights
what are the characteristics of atypical absence seizure
- starring spell
- brief warnings
- peculiar behaviour during seizure
- confusion after
- ECG atypical spike and wave patterns
what are the characteristics of a myoclonic seizure
- sudden/ eccessive jerk of body/ extremities
- forceful enough to cause fall
- brief/ may occur in clusters
what are the characteristics of atonic seizures?
- involves tonic episode
- person falls
- consciousness returns by tie person hits ground/ can resume normal activity
- great risk for head injury
describe a tonic seizure
involve sudden onset of sustained increased tone in extensor muscle
describe clonic seizures
- begin with LOS and sudden loss of muscle tone
- followed by limb jerking that may/ may not be symmetrical
describe focal (partial) seizures
- electrical discharges from one area of brain resulting in unilateral manifestations
- caused by focal irritations
- begin in specific region of cortex
describe a focal aware seizure (simple partial seizure)
- no LOC
- rarely lasts longer than 1min
- may involve motor, sensory or autonomic phenomena
what can focal impaired awareness seizures involve?
- behavioural
- emotional
- affective
- sensory
- cognitive function
what are the characteristics of a focal impaired awareness seizures
- alteration in LOC
- lasts longer than 1 min
- followed by period of postictal confusion
- lip smacking
- psychosensory symptoms
what psychosensory symptoms can occur during a focal impaired awareness seizure
- disorientation of visual, auditory sensations
- alterations in memory/ thought process
- alterations in sexual function
describe status epilepticus
- state of constant seizure
- seizures recur in rapid succession without return to consciousness between seizures
- causes brain to use more energy than its supplied
describe tonic-clonic status epilepticus
- most dangerous
- cause ventilatory insufficiency, hypoxemia, arrhythmias
What are complications that can result from seizures?
- severe injury/ death
- social stigma
- discrimination in employment/ education
- driving sanctions
- depression
what are diagnostics and treatments for seizures?
- seizure history
- physical exam
- EEG
- blood work
- CT
- MRI
- medications
- surgery
- counselling
- special diet (keto)
What are some triggers for seizures?
- 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
prior to a seizure what can a nurse do to ensure patient safety?
- place padding Lining in bed
- ensure safety check has been completed
What should the nurse do while seizure is occurring?
- ensure safe area/ patent airway
- stay with client until seizure passes
- turn patient on side
- apply oxygen
- suction prn
- assist with ventilation
What should the nurse NOT do while seizure is occurring?
- restrain patient
- insert anything into patients mouth
what does the nurse need to continue to monitor in a patient who had a seizure?
- vital signs
- LOC
- GCS
when documenting post seizure what do you need to include ?
- events preceding
- when the seizure occurred
- length of seizure for each phase
- what occurred each phase
when using oral suctioning for seizures you use suction to what?
- remove secretions that obstruct airway
- ventilation
- get secretions for diagnostic purposes
What supplies is needed for suctioning?
- clean hands
- gloves
- yankauer
- suction tubing and canister
for suctioning as adult the suction should be set at what?
100-150
What is the primary drug leading to health-related problems in North America that is the most widely consumed substance?
alcohol
does alcohol cross the blood brain barrier? What does this cause?
yes, when patient withdrawals from alcohol neurochemicals changes occur
What are some medical conditions associated with unhealthy alcohol use ?
- hypertension
- CV disease
- liver disease
- pancreatitis
- gastritis
- esophagitis
- done marrow suppression
- chronic infectious diseases
- cancer
- psychiatric disorders
What are some challenges when people are admitted with AWS?
- hypovolemia/ dehydration
- malnutrition
- electrolyte imbalances
How does excessive alcohol impact sleep?
body doesn’t go into REM sleep
in regards to challenges with people when they are admitted with AWS describe hypovolemia/ dehydration
- alcohol diuretic
- nausea/ vomiting
- poor appetite
- not drinking enough water
- diaphoresis
in regards to challenges with people when they are admitted with AWS describe malnutrition
- alcohol causes gastritis and pancreatitis
- reduces food intake/ absorption - not eating nutritious diet when drinking
in regards to challenges with people when they are admitted with AWS describe electrolyte imbalances
- malnourished have low levels of many electrolytes
- malnourished clients come to hospital at risk of referring syndrome
what can thiamine (B1) deficiency cause in alcoholics?
- beriberi
- wernicke’s encephalopathy
what causes beriberi
diet deficient in thiamine
what are the 2 types of beriberi? describe them
- dry beriberi
- involves development of peripheral neuropathy - wet beriberi
- involves progression to cardiomegaly, HF, peripheral edema
describe Wernicke’s encaphalopathy
- 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
Why do alcoholics have vitamins deficiencies?
- poor diet
- unable to absorb vitamins
- liver unable to store vitamins in cirrhosis
What are manifestations of wenicke’s encephalopathy?
- ataxia
- nystagmus
- confusion
what are signs and symptoms of Korsakoff’s psychosis?
- inability to form new memories
- back of insight into condition
- patient makes up stories
what happens when someone has minor withdrawals?
- insomnia
- tremors
- mid anxiety
- GI upset
- headache
- sweating
- palpitations
- starts 6hrs after last drink
- resolves after 12-48hrs
what happens when someone has major withdrawals?
- dysrhythmias
- more autonomic hyperactivity
- seizures
- hallucinations
- start around 6hrs
- resolves after 72hrs
What are the stages of alcohol withdrawal (AWS)
- 6-12hrs
- minor withdrawal symptoms - 12-14hrs
- hallucinations - 24-48hrs
- seizures - 48-72hrs
- delirium
what are the precursors to withdrawal seizures?
- long history of alcohol use
- +40yrs old
What are some risk factors for delirium tremens?
- chronic alcohol use
- history of previous DT
- +30yrs old
- severe withdrawal symptoms at presentation
- prior detox
in regards to the kindling phenomenon what happens with each episode of alcohol use and alcohol withdrawal even if mild ?
brain becomes more:
- excitable
- sensitive to effects of alcohol withdrawal
in regards to the kindling phenomenon what happens with each episode of alcohol withdrawal?
- clinical manifestations become more severe
- people become increasingly likely to experience seizure/ DT
what 2 drugs are most commonly used for alcohol withdrawal syndrome in regards to a CIWA ?
- diazepam
- lorazepam
if AWS is suspected, what common tests are used?
- CBC/ electrolytes
- liver function test
- total protein/ albumin
- lipase
- glucose
- ECG
