Week 10: Neurological Assessment Flashcards
Huber’s Neuro Assessment
Alert/oriented x3?
Speech clear/understandable
Responsiveness to questions
memory intact
moves all extremities
numbness/tingling
headache/dizziness
Hubert focused near assessment
LOC
Speech
Orientation (person, place, date)
response to questions/stimuli
memory/thought process
Pupil (PERRLA)
Cranial nerve function
motor function
sensory function
reflexes
PERRLA Assessment
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?
Average pupil size
2-8mm
Dilated pupil size
> 8mm
Constricted pupil size
<2mm
What can cause unilateral dilation
brain hematoma
brainstem herniation
migraine
compressed cranial nerve #3
What can cause bilateral dilation/fixed pupil
midbrain injury
poor prognosis if >24hours or GCS <3
What causes bilateral dilation/sluggish pupils
eye diseases
illicit substances (cocaine/LSD/MDMA)
post seizure
what causes bilateral constriction
brain trauma
opioids/narcotics
medications
enviro toxins
eye trauma
diseases
heat stroke
What causes unilateral constriction
horner’s syndrome
iris inflammation
adhesions
medication (pilocarpine)
How many cranial nerves are there
12 cranial nerves that send signals between your brain, face, neck, and torso
Types of nerves
- Sensory: allow taste, smell, hear, and feel
- Motor: allow facial expressions, blink, vocalize and swallow food
nerve 1
Olfactory
Nerve 2
optic
Nerve 3
Oculomotor
Nerve 4
trochlear
Neve 5
Trigeminal
Nerve 6
abducens
Nerve 7
Facial
Nerve 8
Acoustic
Nerve 9
glossopharyngeal
Nerve 10
Vagus
Nerve 11
accessory
Nerve 12
hypoglossal
How can sensory function be tested
by testing dermatomes
What is a dermatome
an area or zone of skin
Each dermatome
is associated with a single spinal nerve
How many spinal nerves/dermatomes are there
31 pairs of spinal nerves, but only 30 dermatomes
What can local anaesthetics and anti seizure drugs do
prevent the transmission of nerve fibres entering the spinal cord
How to test dermatomes
use a cotton swab and the stick to test pain or light sensation, pt closes eyes and tells what sensation they feel
test bilaterally
How many cervical dermatomes
7 (C1-C8)
C1
no dermatomes
C2
back of head
C3
Lower head and upper neck
C4
Lower neck and upper shoulders
C5
Upper shoulders and collar bones
C6
Lateral forearm and thumb
C7
upper back, back of arms, index/middle fingers
C8
Lower back, inner arms, ring/little fingers
How many thoracic dermatomes
12
T1
Upper chest/back, inner arms
T2-T4
upper chest/back
T5-T7
mid chest/back
T8/T9
upper abdomen/mid back
T10/T11
Abdomen and mid back
T12
lower abdomen and mid back
How many lumbar dermatomes
5
L1
Lower back, hips and groin
L2/L3
lower back, front and inside of thigh
L4
lower back, front of thigh, calf, knee, inner ankle
L5
lower back, front and outside of calf, top and bottom of foot and toes 1-3
How many sacral dermatomes
5
S1
lower back, back of thigh, and calf toes 4/5, and outer ankle bone
S2
butt, back of thigh/calf, heel bone, genitals
S3
mid butt, genitals
S4
perianal region/skin
S5
perianal region/skin immediately next to anus
What are some methods to assess motor function
Balance
- gait smooth? coordinated arm movement? effortless
- sensory ataxia: Romberg test
coordination
finger to fingr
heel to shin
RAM
Muscles
strength
symmetry
Reflexes
an instantaneous and involuntary response to stimulus
Normal reflex indicates a pathway between
the stimulus/sensory neuron/interneuron/motor neuron/muscle
how to test Deep Tendon Reflex (DTR)
percussion hammer
Triceps reflex
C7 and C8
Biceps reflex
C5 and C6
Brachioradialis reflex
C5 and C6
Patellar reflex
L2, L3, L4
Achilles reflex
spinal cord S1 and S2
Plantar reflex
L2, L3, L4
Scoring reflexes
0 absent
1 diminished
2 brisk; normal
3 very brisk
4 clonus or repetitive contraction
What can cause abnormal reflexes
peripheral neuropathy
nerve compression
trauma or lesions
medications
hormone/electrolyte imbalances
nutrient deficiencies
disease
What is a stroke
When blood flow stops to any part of the brain, ischemia occurs, and brain cells are damaged
what is stroke often caused by
Blockage (ischemic) or spontaneous bleeding (hemorrhagic)
What underlying conditions can cause a stroke
Tumor, infection, brain swelling, congenital abnormalities
What is an ischemic stroke
Blood clot stops the flow of blood to an area of the brain
What is a hemorrhagic stroke
weakened/diseased blood vessels rupture
Right sided brain damage
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
Left sided brain damage
paralyzed right side
impaired speech language
slow performance
aware of deficits (depression, anxiety)
impaired comprehension related to language, math
What nursing assessments are used with stroke in acute care
GCS
National institute of health stroke scale
canadian neurological scale
Toronto bedside swallowing Screen
IH adult swallowing screen
IH stroke PPO
What is a seizure
a sudden onset of uncontrolled electrical activity in one or more areas of the brain
Seizures symptoms
LOC changes
emotion changes
loss of muscle control
sensory changes
loss of bladder/bowel
respiratory changes
staring or rapid blinking
Seizure 3 key features for classification
- where begins in brain
- level of awareness during a seizure
- describing the other features of the seizure
Focal seizure
onset is one area on one side of the brain
Generalized seizures
involves both sides of the brain at the onset
Unknown onset
not known may be determined later
Focal to bilateral seizures
starts in one side or part of the brain an spreads to both sides
Focal aware
awareness remains intact, even if the person is unable to talk or respond during a seizure
focal impaired awareness
awareness is impaired or affected at any time during the seizure
Awareness unknown
not always possible to know if a person is aware or not (eg occurs at night, lives alone)
Generalized seizures
presumed to affects a person’s awareness or consciousness
Focal motor seizure
Body movement occurs (twitch, jerk) or automatisms (chewing, lip licking)
Focal non-motor seizure
changes in sensation, emotions, thinking, or experiences
generalized motor seizure
generalized tonic clonic
describes seizures with stiffening (tonic) and jerking (clonic)
Generalized non-motor seizure
primarily absence seizures involve brief changes in awareness, staring, and may present with automatisms
Prodromal Phase
Precedes seizure with signs (headache, confusion, mood/behaviour changes)
can occur several days or minutes prior to seizure
Early ictal/aural phase
sensory warning (vision changes, smells, auditory sensations, fear, panic, nausea, de je vu) prior to seizure
an aura is a focal seizure
Ictal phase
seizure activity, loss of awareness, repeated movements, convulsions, tachycardia, trouble breathing
Posictal phase
rest and recovery (N, muscle weakness, exhaustion, fear, fatigue, decreased LOC)
Status epilepticus
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
What does status epilepticus cause the brain to do?
Causes the brain to use more energy than is supplied
- neurone become exhausted and cease to function
- permanent brain damage can result
Tonic-clonic status epilepticus
most dangerous as it can cause ventilatory insufficiency, hypoxemia, cardiac arrhythmias, hyperthermia, and systemic acidosis
Diagnostics and treatment of seizures
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
Triggers for seizures
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
What are seizure precautions
padding lining the bed
bedside safety check (functioning, O2)
What to do during a seizure
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
Post Ictal monitor
VS
LOC, GCS
Ictal assessment
abnormal RR, rhythm, sounds, apnea
airway occlusion
HTN, tachycardia, or bradycardia
excessive salivation
Post Ictal Assessment
any precipitating factors
bitten tongue, soft tissue damage
cyanosis
bowel/urinary incontinence
diaphoresis
weakness, paralysis, ataxia
neuro vitals
Oral suction to:
remove obstructing secretions
facilitate ventialtion
obtain secretions for diagnosis purposes
prevent infection that may result from accumulated secretions
Alcohol use disorder
a medical condition characterized by an impaired ability to stop or control alcohol use despite adverse social, occupational or health consequences
how many Canadians have alcohol dependency
1 in 10
How does alcohol re wire the brain?
neurotransmitters in the CNS are heavily suppressed by alcohol consumption, it inhibits excitatory receptors (glutamate) of the CNS and enhances inhibitory receptors (GABA)
short term alcohol effects on CNS
initial relaxation
decreased inhibition
lack of coordination
impaired judgement
slurred speech
anxiety or agitation
hypotension
bradycardia
bradypnea
Long term effects of alcohol on the CNS
Wernicke’s encephalopathy
Korsakoff’s syndrome
impaired cognition
decreased psychomotor skills
impaired abstract thinking and memory
sleep disturbances
depression/labile mood
attention deficit
seizures
What is the CAGE tool
- Have you ever felt you ought to Cut down on your drinking
- Have people Annoyed you by criticizing your drinking
- Have you ever felt bad or Guilty about your drinking?
- Have you every had a drink in the morning (Eye opener) to steady your nerves or get rid of a hangover?
Mild to moderate AWS symptoms
tremors
anxiety
N/V
headahce
tachycardia
diaphoresis
irritability
confusion
insomnia
nightmares
HTN
Severe AWS symptoms
Profound confusion
agitation
aggression
fever
seizures
tactile disturbances
auditory and/or visual hallucinations
excessive diaphoresis
tachycardia, tachypnea
tremors
HTN
What is CIWA
standardized assessment tool used to assess and monitor symptoms caused by alcohol withdrawall
10 most common symptoms CIWA assesses?
N/V
tremor
tactile disturbances
auditory disturbances
paroxysmal sweats
visual disturbances
anxiety
headache
agitation
orientation/clouding od sensorium
Stages of alcohol withdrawal
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
withdrawal seizures typically occur
24 hours after last drink though different for everyone, can occur as soon as 2 hrs or 48 hours after
Whos at increased risk for withdrawal seizures
long Hx of use
aged >40
Increased risk for delirium tremens
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
Kindling phenomenon
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
with each episode of alcohol withdrawal
clinical manifestations become more severe
people become increasingly likely to experience seizures and DT
How does hypovolemia and dehydration occur with alcohol
alcohol is a diuretic
N/V
poor appetite due to gastritis
not drinking adequate water
diaphoresis
What is thiamine essential for
energy metabolism converting carbs to glucose
What is beri beri
a diseases caused thiamine deficiency
Dry beri beri
affects the CNS and PNS
Wet beriberi
affects the heart and circulatory system
Dry BeriBeri can lead to
wernicke’s encephalopathy
korsakoffs syndrome
Wernicke’s encephalopathy
acute/sudden syndrome requiring urgent tmt
swelling causes damages to nerves and blood vessels in brain
ataxia confusion, nystagmus
Korsakoff’s syndrome
irreversible significant short term memory impairment
inability to learn new things or retain new info
some loss of long term memory
