week 5: neurological assessment Flashcards

1
Q

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\_\_\_ \_\_\_?
A
When?
What does it feel like?
Witnessed?
Mechanism of injury?
Medications?
Association symptoms?
How often?
Bowel & Bladder control?
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2
Q

arousal - depends on the ___ ___ ___ (___)

A

reticular activating system (RAS)

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3
Q

cognition - includes T___ P___, M___, P___, P___ S___ & E___

A

thought processes, memory, perception, problem solving & emotions

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4
Q

level of consciousness is the ___ ___ aspect of a neurological assessment

A

most important

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5
Q

conscious level ___ ___ any other neurological change is noted & is often ___

A

deteriorates before, subtle

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6
Q

the most widely recognised assessment tool of level of consciousness is the ___ ___ ___ (___)

A

Glasgow Coma Scale (GCS)

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7
Q

a ___ level of consciousness is a common finding in ___ illness & disease

A

depressed, acute

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8
Q

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___,

A

intracranial

hypoxia, hypotension, hypoglycaemia, hypovolaemia, hepatic encephalopathy, renal failure

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9
Q

be concerned if you observe:

P___ changes,
B___ changes,
limitations in ___ or alterations in ___
or a GCS score fall lower of equal to ___ points

A

pupillary,
behaviour,
movement, sensations
2

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10
Q

A GCS is used as a way to consistently ___ about the ___ of ___ of patient with neurological injury

A

communicate, level, consciousness

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11
Q

findings of the GCS is used to guide ___ ___ and ___ trends of ___.

A

decision making, monitor, responsiveness

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12
Q

the options for central pain is ___ pressure or ___ squeeze

A

supraorbital, trapezius

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13
Q

for peripheral pain the options is ___ ___ pressure of ___-___ ___ pressure

A

nail bed, inter-phalangeal joint

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14
Q

inspect pupils for ___, ___ & ___ to light

A

shape, symmetry & reaction

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15
Q

parasympathetic control of the pupil occurs with the ___ ___ (___ ___) - in response to light the pupil constricts in size

A

oculomotor nerve (CN III)

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16
Q

changes n respiratory patterns assist in identifying the level of ___ dysfunction or injury

A

brainstem

17
Q

abnormal respiratory patterns include:
CCCAA

C\_\_\_-\_\_\_ breathing 
C\_\_\_ \_\_\_ \_\_\_
C\_\_\_ breathing
A\_\_\_
A\_\_\_ breathing
A
Cherne-stokes 
Central neurogenic hyperventilation
Cluster
Apneusis
Ataxic
18
Q

changes in breathing patterns may only occur after ___ neurological insult or injury

A

significant

19
Q
A
20
Q
A
21
Q
A
22
Q

assessment strategies for LOC are:

A\_\_\_ (acronym)
G\_\_\_ (acronym)
L\_\_\_ s\_\_\_
P\_\_\_
C\_\_\_ n\_\_\_
V\_\_\_ s\_\_\_
A
AVPU
GCS
Limb strength
Pupils
Cranial nerves
Vital signs
23
Q

pain serves as a ___ ___ to ___ or ___ tissue injury

A

protective mechanism, prevent, reduce

24
Q

pain ___ the body to ___ from noxious stimuli

A

encourages, withdraw

25
Q

pain is useful for helping determine the ___ of ___ tissue injury

A

location, potential

26
Q

nurses and midwives must ___ & ___ on the person’s description of their pain when developing a ___ ___ ___

A

understand & rely, pain management plan

27
Q

pain thresholds & tolerances ___

A

vary

28
Q
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)
A

prostaglandins, bradykinin, serotonin, substance P, Histamine

29
Q

tissue damage can occur due to an inadequate ___ ___, direct ___ & ___ insult.

A

blood supply, trauma, chemical

30
Q

sensitising substances ___ nociceptors and ___ their membranes for movement of ___ ___

A

activate, prepare, electrical impulses

31
Q

descending fibres release substances that produce analgesia by blocking the transmission of noxious stimuli: EE&E

E___ opioids
E___ & E___

A

endogenous, encephalins & endorphins

32
Q
A