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NRSG 202 > Week 10: Neurological Assessment > Flashcards

Week 10: Neurological Assessment Flashcards

1
Q

Huber’s Neuro Assessment

A

Alert/oriented x3?
Speech clear/understandable
Responsiveness to questions
memory intact
moves all extremities
numbness/tingling
headache/dizziness

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2
Q

Hubert focused near assessment

A

LOC
Speech
Orientation (person, place, date)
response to questions/stimuli
memory/thought process
Pupil (PERRLA)
Cranial nerve function
motor function
sensory function
reflexes

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3
Q

PERRLA Assessment

A

P: Pupils
E: Equal
- assess size prior to testing for reaction
- 20% of ppl naturally have asymmetrical pupils “physiological anisocoria”
R: Round?
R: Reactive to light
- is reaction brisk or sluggish
- non reactive or fixed
A: Accommodation
- do pupils dilate when focusing on distant object
- do they constrict/converge when focus shifts to an object close up?

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4
Q

Average pupil size

A

2-8mm

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5
Q

Dilated pupil size

A

> 8mm

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6
Q

Constricted pupil size

A

<2mm

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7
Q

What can cause unilateral dilation

A

brain hematoma
brainstem herniation
migraine
compressed cranial nerve #3

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8
Q

What can cause bilateral dilation/fixed pupil

A

midbrain injury
poor prognosis if >24hours or GCS <3

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9
Q

What causes bilateral dilation/sluggish pupils

A

eye diseases
illicit substances (cocaine/LSD/MDMA)
post seizure

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10
Q

what causes bilateral constriction

A

brain trauma
opioids/narcotics
medications
enviro toxins
eye trauma
diseases
heat stroke

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11
Q

What causes unilateral constriction

A

horner’s syndrome
iris inflammation
adhesions
medication (pilocarpine)

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12
Q

How many cranial nerves are there

A

12 cranial nerves that send signals between your brain, face, neck, and torso

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13
Q

Types of nerves

A
  1. Sensory: allow taste, smell, hear, and feel
  2. Motor: allow facial expressions, blink, vocalize and swallow food
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14
Q

nerve 1

A

Olfactory

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15
Q

Nerve 2

A

optic

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16
Q

Nerve 3

A

Oculomotor

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17
Q

Nerve 4

A

trochlear

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18
Q

Neve 5

A

Trigeminal

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19
Q

Nerve 6

A

abducens

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20
Q

Nerve 7

A

Facial

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21
Q

Nerve 8

A

Acoustic

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22
Q

Nerve 9

A

glossopharyngeal

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23
Q

Nerve 10

A

Vagus

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24
Q

Nerve 11

A

accessory

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25
Q

Nerve 12

A

hypoglossal

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26
Q

How can sensory function be tested

A

by testing dermatomes

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27
Q

What is a dermatome

A

an area or zone of skin

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28
Q

Each dermatome

A

is associated with a single spinal nerve

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29
Q

How many spinal nerves/dermatomes are there

A

31 pairs of spinal nerves, but only 30 dermatomes

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30
Q

What can local anaesthetics and anti seizure drugs do

A

prevent the transmission of nerve fibres entering the spinal cord

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31
Q

How to test dermatomes

A

use a cotton swab and the stick to test pain or light sensation, pt closes eyes and tells what sensation they feel
test bilaterally

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32
Q

How many cervical dermatomes

A

7 (C1-C8)

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33
Q

C1

A

no dermatomes

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34
Q

C2

A

back of head

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35
Q

C3

A

Lower head and upper neck

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36
Q

C4

A

Lower neck and upper shoulders

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37
Q

C5

A

Upper shoulders and collar bones

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38
Q

C6

A

Lateral forearm and thumb

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39
Q

C7

A

upper back, back of arms, index/middle fingers

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40
Q

C8

A

Lower back, inner arms, ring/little fingers

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41
Q

How many thoracic dermatomes

A

12

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42
Q

T1

A

Upper chest/back, inner arms

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43
Q

T2-T4

A

upper chest/back

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44
Q

T5-T7

A

mid chest/back

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45
Q

T8/T9

A

upper abdomen/mid back

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46
Q

T10/T11

A

Abdomen and mid back

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47
Q

T12

A

lower abdomen and mid back

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48
Q

How many lumbar dermatomes

A

5

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49
Q

L1

A

Lower back, hips and groin

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50
Q

L2/L3

A

lower back, front and inside of thigh

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51
Q

L4

A

lower back, front of thigh, calf, knee, inner ankle

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52
Q

L5

A

lower back, front and outside of calf, top and bottom of foot and toes 1-3

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53
Q

How many sacral dermatomes

A

5

54
Q

S1

A

lower back, back of thigh, and calf toes 4/5, and outer ankle bone

55
Q

S2

A

butt, back of thigh/calf, heel bone, genitals

56
Q

S3

A

mid butt, genitals

57
Q

S4

A

perianal region/skin

58
Q

S5

A

perianal region/skin immediately next to anus

59
Q

What are some methods to assess motor function

A

Balance
- gait smooth? coordinated arm movement? effortless
- sensory ataxia: Romberg test

coordination
finger to fingr
heel to shin
RAM

Muscles
strength
symmetry

60
Q

Reflexes

A

an instantaneous and involuntary response to stimulus

61
Q

Normal reflex indicates a pathway between

A

the stimulus/sensory neuron/interneuron/motor neuron/muscle

62
Q

how to test Deep Tendon Reflex (DTR)

A

percussion hammer

63
Q

Triceps reflex

A

C7 and C8

64
Q

Biceps reflex

A

C5 and C6

65
Q

Brachioradialis reflex

A

C5 and C6

66
Q

Patellar reflex

A

L2, L3, L4

67
Q

Achilles reflex

A

spinal cord S1 and S2

68
Q

Plantar reflex

A

L2, L3, L4

69
Q

Scoring reflexes

A

0 absent
1 diminished
2 brisk; normal
3 very brisk
4 clonus or repetitive contraction

70
Q

What can cause abnormal reflexes

A

peripheral neuropathy
nerve compression
trauma or lesions
medications
hormone/electrolyte imbalances
nutrient deficiencies
disease

71
Q

What is a stroke

A

When blood flow stops to any part of the brain, ischemia occurs, and brain cells are damaged

72
Q

what is stroke often caused by

A

Blockage (ischemic) or spontaneous bleeding (hemorrhagic)

73
Q

What underlying conditions can cause a stroke

A

Tumor, infection, brain swelling, congenital abnormalities

74
Q

What is an ischemic stroke

A

Blood clot stops the flow of blood to an area of the brain

75
Q

What is a hemorrhagic stroke

A

weakened/diseased blood vessels rupture

76
Q

Right sided brain damage

A

paralyzed L side
ledt sided neglect
spatial perceptual deficits
tends to deny or minimize problems
rapid performance/short attention span
impulsive, safety problems
impaired judgement

77
Q

Left sided brain damage

A

paralyzed right side
impaired speech language
slow performance
aware of deficits (depression, anxiety)
impaired comprehension related to language, math

78
Q

What nursing assessments are used with stroke in acute care

A

GCS
National institute of health stroke scale
canadian neurological scale
Toronto bedside swallowing Screen
IH adult swallowing screen
IH stroke PPO

79
Q

What is a seizure

A

a sudden onset of uncontrolled electrical activity in one or more areas of the brain

80
Q

Seizures symptoms

A

LOC changes
emotion changes
loss of muscle control
sensory changes
loss of bladder/bowel
respiratory changes
staring or rapid blinking

81
Q

Seizure 3 key features for classification

A
  1. where begins in brain
  2. level of awareness during a seizure
  3. describing the other features of the seizure
82
Q

Focal seizure

A

onset is one area on one side of the brain

83
Q

Generalized seizures

A

involves both sides of the brain at the onset

84
Q

Unknown onset

A

not known may be determined later

85
Q

Focal to bilateral seizures

A

starts in one side or part of the brain an spreads to both sides

86
Q

Focal aware

A

awareness remains intact, even if the person is unable to talk or respond during a seizure

87
Q

focal impaired awareness

A

awareness is impaired or affected at any time during the seizure

88
Q

Awareness unknown

A

not always possible to know if a person is aware or not (eg occurs at night, lives alone)

89
Q

Generalized seizures

A

presumed to affects a person’s awareness or consciousness

90
Q

Focal motor seizure

A

Body movement occurs (twitch, jerk) or automatisms (chewing, lip licking)

91
Q

Focal non-motor seizure

A

changes in sensation, emotions, thinking, or experiences

92
Q

generalized motor seizure

A

generalized tonic clonic
describes seizures with stiffening (tonic) and jerking (clonic)

93
Q

Generalized non-motor seizure

A

primarily absence seizures involve brief changes in awareness, staring, and may present with automatisms

94
Q

Prodromal Phase

A

Precedes seizure with signs (headache, confusion, mood/behaviour changes)
can occur several days or minutes prior to seizure

95
Q

Early ictal/aural phase

A

sensory warning (vision changes, smells, auditory sensations, fear, panic, nausea, de je vu) prior to seizure
an aura is a focal seizure

96
Q

Ictal phase

A

seizure activity, loss of awareness, repeated movements, convulsions, tachycardia, trouble breathing

97
Q

Posictal phase

A

rest and recovery (N, muscle weakness, exhaustion, fear, fatigue, decreased LOC)

98
Q

Status epilepticus

A

A state of constant seizure or when seizures recur in rapid succession without return to consciousness between seizures
neuro emegency
can involve any type of seizure

99
Q

What does status epilepticus cause the brain to do?

A

Causes the brain to use more energy than is supplied
- neurone become exhausted and cease to function
- permanent brain damage can result

100
Q

Tonic-clonic status epilepticus

A

most dangerous as it can cause ventilatory insufficiency, hypoxemia, cardiac arrhythmias, hyperthermia, and systemic acidosis

101
Q

Diagnostics and treatment of seizures

A

Client Hx and physical examination
seizure history
EEG, blood work, CT, MRI, lumbar puncture
medications
vagal nerve stimulation (thought to interrupt the synchronization of epileptic brain wave activity)
surgery
counselling
special diet

102
Q

Triggers for seizures

A

Stress
excessive excitement/stimulation
excessive fluid intake
extremely low BS in DM’s
Sunlight, heat, humidity
flickering lights
skipping meals, poor nutrition
illness, fever, allergies
lack of sleep
withdrawal from meds, drugs, alcohol
missed medication

103
Q

What are seizure precautions

A

padding lining the bed
bedside safety check (functioning, O2)

104
Q

What to do during a seizure

A

ensure patient is safe
ensure airwau
stay w pt
DO NOT restrain
turn on side
apply O2 as needed
DO NOT insert anything into mouth
establish IV and administer medication as ordered]
suction PRN
assist with ventilation if patient does not breath after seizure
call a code BLUE if patient status is warranted

105
Q

Post Ictal monitor

A

VS
LOC, GCS

106
Q

Ictal assessment

A

abnormal RR, rhythm, sounds, apnea
airway occlusion
HTN, tachycardia, or bradycardia
excessive salivation

107
Q

Post Ictal Assessment

A

any precipitating factors
bitten tongue, soft tissue damage
cyanosis
bowel/urinary incontinence
diaphoresis
weakness, paralysis, ataxia
neuro vitals

108
Q

Oral suction to:

A

remove obstructing secretions
facilitate ventialtion
obtain secretions for diagnosis purposes
prevent infection that may result from accumulated secretions

109
Q

Alcohol use disorder

A

a medical condition characterized by an impaired ability to stop or control alcohol use despite adverse social, occupational or health consequences

110
Q

how many Canadians have alcohol dependency

A

1 in 10

111
Q

How does alcohol re wire the brain?

A

neurotransmitters in the CNS are heavily suppressed by alcohol consumption, it inhibits excitatory receptors (glutamate) of the CNS and enhances inhibitory receptors (GABA)

112
Q

short term alcohol effects on CNS

A

initial relaxation
decreased inhibition
lack of coordination
impaired judgement
slurred speech
anxiety or agitation
hypotension
bradycardia
bradypnea

113
Q

Long term effects of alcohol on the CNS

A

Wernicke’s encephalopathy
Korsakoff’s syndrome
impaired cognition
decreased psychomotor skills
impaired abstract thinking and memory
sleep disturbances
depression/labile mood
attention deficit
seizures

114
Q

What is the CAGE tool

A
  1. Have you ever felt you ought to Cut down on your drinking
  2. Have people Annoyed you by criticizing your drinking
  3. Have you ever felt bad or Guilty about your drinking?
  4. Have you every had a drink in the morning (Eye opener) to steady your nerves or get rid of a hangover?
115
Q

Mild to moderate AWS symptoms

A

tremors
anxiety
N/V
headahce
tachycardia
diaphoresis
irritability
confusion
insomnia
nightmares
HTN

116
Q

Severe AWS symptoms

A

Profound confusion
agitation
aggression
fever
seizures
tactile disturbances
auditory and/or visual hallucinations
excessive diaphoresis
tachycardia, tachypnea
tremors
HTN

117
Q

What is CIWA

A

standardized assessment tool used to assess and monitor symptoms caused by alcohol withdrawall

118
Q

10 most common symptoms CIWA assesses?

A

N/V
tremor
tactile disturbances
auditory disturbances
paroxysmal sweats
visual disturbances
anxiety
headache
agitation
orientation/clouding od sensorium

119
Q

Stages of alcohol withdrawal

A

6-12 minor symptoms
12-24 hallucinations (visual, tactile, auditory)
24-48 withdrawal seizures, generalized tonic-clonic seizures
48-72 delirium, hallucinations, agitation, disorientation, diaphoresis

120
Q

withdrawal seizures typically occur

A

24 hours after last drink though different for everyone, can occur as soon as 2 hrs or 48 hours after

121
Q

Whos at increased risk for withdrawal seizures

A

long Hx of use
aged >40

122
Q

Increased risk for delirium tremens

A

heavy prolonged use
Hx of seizures or DT
age >30
concurrent illness and more medical comorbidities
prior detox
occur 48-72 hours after last drink

123
Q

Kindling phenomenon

A

with each episode of alcohol use and alcohol withdrawal (even if mild) the brain becomes more excitable and sensitive to the effects of alcohol withdrawal

124
Q

with each episode of alcohol withdrawal

A

clinical manifestations become more severe
people become increasingly likely to experience seizures and DT

125
Q

How does hypovolemia and dehydration occur with alcohol

A

alcohol is a diuretic
N/V
poor appetite due to gastritis
not drinking adequate water
diaphoresis

126
Q

What is thiamine essential for

A

energy metabolism converting carbs to glucose

127
Q

What is beri beri

A

a diseases caused thiamine deficiency

128
Q

Dry beri beri

A

affects the CNS and PNS

129
Q

Wet beriberi

A

affects the heart and circulatory system

130
Q

Dry BeriBeri can lead to

A

wernicke’s encephalopathy
korsakoffs syndrome

131
Q

Wernicke’s encephalopathy

A

acute/sudden syndrome requiring urgent tmt
swelling causes damages to nerves and blood vessels in brain
ataxia confusion, nystagmus

132
Q

Korsakoff’s syndrome

A

irreversible significant short term memory impairment
inability to learn new things or retain new info
some loss of long term memory

NRSG 202 (8 decks)

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