week 5: neurological assessment Flashcards
the focus of a neurological health history interview:
3, 2, 3 1’s
W\_\_\_? W\_\_\_ does it \_\_\_ like? W\_\_\_? M\_\_\_ of \_\_\_? M\_\_\_? A\_\_\_ \_\_\_? H\_\_\_ \_\_\_? B\_\_\_ & B\_\_\_ \_\_\_?
When? What does it feel like? Witnessed? Mechanism of injury? Medications? Association symptoms? How often? Bowel & Bladder control?
arousal - depends on the ___ ___ ___ (___)
reticular activating system (RAS)
cognition - includes T___ P___, M___, P___, P___ S___ & E___
thought processes, memory, perception, problem solving & emotions
level of consciousness is the ___ ___ aspect of a neurological assessment
most important
conscious level ___ ___ any other neurological change is noted & is often ___
deteriorates before, subtle
the most widely recognised assessment tool of level of consciousness is the ___ ___ ___ (___)
Glasgow Coma Scale (GCS)
a ___ level of consciousness is a common finding in ___ illness & disease
depressed, acute
a depressed level of consciousness can occur due to ___ disease or as a result of a systemic insult:
H___, H___, H___, H___, H___ E___,
R___ f___,
intracranial
hypoxia, hypotension, hypoglycaemia, hypovolaemia, hepatic encephalopathy, renal failure
be concerned if you observe:
P___ changes,
B___ changes,
limitations in ___ or alterations in ___
or a GCS score fall lower of equal to ___ points
pupillary,
behaviour,
movement, sensations
2
A GCS is used as a way to consistently ___ about the ___ of ___ of patient with neurological injury
communicate, level, consciousness
findings of the GCS is used to guide ___ ___ and ___ trends of ___.
decision making, monitor, responsiveness
the options for central pain is ___ pressure or ___ squeeze
supraorbital, trapezius
for peripheral pain the options is ___ ___ pressure of ___-___ ___ pressure
nail bed, inter-phalangeal joint
inspect pupils for ___, ___ & ___ to light
shape, symmetry & reaction
parasympathetic control of the pupil occurs with the ___ ___ (___ ___) - in response to light the pupil constricts in size
oculomotor nerve (CN III)
changes n respiratory patterns assist in identifying the level of ___ dysfunction or injury
brainstem
abnormal respiratory patterns include:
CCCAA
C\_\_\_-\_\_\_ breathing C\_\_\_ \_\_\_ \_\_\_ C\_\_\_ breathing A\_\_\_ A\_\_\_ breathing
Cherne-stokes Central neurogenic hyperventilation Cluster Apneusis Ataxic
changes in breathing patterns may only occur after ___ neurological insult or injury
significant
assessment strategies for LOC are:
A\_\_\_ (acronym) G\_\_\_ (acronym) L\_\_\_ s\_\_\_ P\_\_\_ C\_\_\_ n\_\_\_ V\_\_\_ s\_\_\_
AVPU GCS Limb strength Pupils Cranial nerves Vital signs
pain serves as a ___ ___ to ___ or ___ tissue injury
protective mechanism, prevent, reduce
pain ___ the body to ___ from noxious stimuli
encourages, withdraw
pain is useful for helping determine the ___ of ___ tissue injury
location, potential
nurses and midwives must ___ & ___ on the person’s description of their pain when developing a ___ ___ ___
understand & rely, pain management plan
pain thresholds & tolerances ___
vary
damaged tissues and cells release various sensitising substances to initiate the pain physiology process: P\_\_\_ (PG) B\_\_\_ (BK) S\_\_\_ (5-HT) S\_\_\_ P (SP) H\_\_\_ (H)
prostaglandins, bradykinin, serotonin, substance P, Histamine
tissue damage can occur due to an inadequate ___ ___, direct ___ & ___ insult.
blood supply, trauma, chemical
sensitising substances ___ nociceptors and ___ their membranes for movement of ___ ___
activate, prepare, electrical impulses
descending fibres release substances that produce analgesia by blocking the transmission of noxious stimuli: EE&E
E___ opioids
E___ & E___
endogenous, encephalins & endorphins
