NSG 101 Neurological System

Symptoms of Cerebral Vascular Accident (CVA )stroke

Facial droop

Unable to feel sensation

Change in vitals

Unexplained fever

Irregular breathing

Progressive paralysis or weakness

Posturing

Seizure activity

Change in pupils size and reaction

Acute mental status change

LOC change

Will have blood monitoring when prescribed these meds

Warfarin

Digoxin

Seizure meds

Neurological system assessment

ABCT

MMSE (Mini Mental State Exam)

GCS (Glasgow Coma Scale)

ABCT neurological assessment

Appearance

Behavior

Cognitive function

Thought process

Mini Mental State Exam (MMSE)

Serials 7 s (you start at 100 and have them subtract 7 )

Name objects

Repeating phrases

Following a 3 step direction

Reading and responding

Writing a sentence

Drawing intersecting pentagon

Glasgow Coma Scale range from best to worst

15 is the best

3 is the worst score

Aphasia

Difficulty with receptive and expressive communication

Normal reaction is documentated as

PERRL

Safety accommodations for neurological disorders patients

Remove rugs

Increase lighting

Use of assistive devices

Safety is important for neurological patients because

They are at risk for falls

Observe eyes for

Pupil size

Shape

Equality

Constriction

And accommodation

Touching your nose and pointing test

Checks for neurological impact

Lumbar puncture

Test the( CSF ) central spinal fluid or pressure

What is an MRI

Why would someone get an MRI

What is an EEG and why do we use it

Tests

CT

MRI

EEG

lumbar puncture

CVA patients need rapid CT scan but it’s usually a

CT test with no contrast because the contrast can mask brain bleed

CVA can be caused by

Clot or brain bleed

Why do we test muscle strength through ROM

Rombergs Test

Feet together and arms at side with eyes open admc and closed without swaying

A fail test is a sign of neurological issues

The cerebellum controls

Your balance and movement

Reflexes test for

nerve or muscle damage

Why do we test reflexes

Too slow

Diminishing (spinal column issues )

Hyperactive (drug use )

Normal pupil diameter is

Receptive communication

Expressive Communication

Glasgow coma scale (GCS) score

Should elevate or stay as it, a decline is a medical concern

Glasgow Coma Scale measures the

Eye response

Verbal response

Motor response

Pupil activity is

Reaction to light

Pupils should be equal and reactive to

Light

PERRL(A)

Signals activity of the brain and nerves

What is the Glasgow Coma Scale

A tool for assessing a clients response to stimuli

If you have a score of 8 on the Glasgow Coma Scale you should

Intubate

What can cause delirium

Levels of consciousness

What can cause acute confusion

Lack of sleep

Stress

Drugs or alcohol

Dehydrated

What is confusion

Lack of understanding or disorderly thoughts

What is delirium

acute onset , may not have underlying medical cause

Delirium usually resolves

Over time or after you are discharged

What can cause delirium

overstimulation

What is dementia

Gradual onset of memory , thinking, and ADL defection

Pertinent information about CVA

Do they use meds

Any hx of seizures

Can they remember what happened

Assess signs and symptoms

Confer with family

Assess senses

Special concerns with elders

Review past hx

Assessment of consciousness : responses

Spontaneous

Normal voice

Loud voice

Tactile (touch)

Noxious stimulation (pain )

Cultures that are more at risk for CVA

African Americans

Native Americans

Hispanics

What can cause a stroke

Buildup of plaque Causing narrow arteries and reduced blood flow

Blood clot

Lack of oxygen

Obtunded

Reduced level of concours res

Risk factors to have a CVA

Uncontrolled and unmonitored blood pressure

High cholesterol and triglycerides

Cardiac issues

Smoking due to hardened and constricted blood vessels

Diabetes

Drugs and alcohol

Age

Teaching points for cerebral vascular accident (CVA)

What is an annurisym

During a CVA this is an emergency because

The tissue is dying

Stokes can trigger

Seizure activity

If the clot is on the left side of the brain it will effect the

Right side of the body

What does neurological system consist of

What is the neurological system

Damage to the hypothalamus can cause

Fever without infection

The brain stem controls

Respiratory