Assessing the Neurological System (NUR235- Exam 2)

What occurs when involuntary muscle contracts in response to a sudden stretch of the muscle caused by tapping its tendon with a reflex hammer?

deep tendon reflexes (DTR's)

What do DTR's provide?

information on the condition of upper and lower motor neurons

When does a loss/ decrease of reflex occur?

injury to motor neuron, nerve roots or peripheral nerves

When does an increase of reflex occur?

injury involves upper motor neuron (brain or spinal cord)

paralysis of all four extremities

quadriplegic

paralysis of the lower portion of the body and of both legs

parapalegic

paralysis of one side of the body

hemiplegic

pain occurring along a nerve

neuralgia

aura

subjective, but recognizable sensation that precedes and signals the onset of convulsion/seizure or migraine headache

What is the order of techniques used to assess the neurological system?

- interview

- inspect

- palpate

What is asked during the interview process?

- reason

- Hx of present illness

- Medical/ Family history

- lifestyle and health promotion

Assessment of the muscles?

- symmetry and body size and extra movements

- palpate grip strength and plantar flexion (pedal pushes)

Assessment of Balance/Gait?

- Walk normally

- Note posture, freedom of movement, symmetry, rhythm and balance

- Gait is steady and opposite arms sway

What is involved in a neuro check?

- LOC

- Pupillary response

- Movement and strength of extremities

- Sensation in extremities

- Vital signs

How to assess gross cranial nerves?

- Face symmetry

- Clear speech

- Vision

- Hearing

- Comprehensible - conversation

What is a Romberg Assessment?

assessment for imbalance and abnormal swaying

How does a nurse perform a romberg assessment?

- stand erect with arms at side and feet together for 20 seconds

- repeat eyes open and closed

When is nuchal rigidity assessed?

if you suspect that the client has meningeal irritation or inflammation from infection or subarachnoid hemorrhage

What is nuchal rigidity?

neck stiffness

How is nuchal rigidity assessed?

touching chin to chest and if not

Decorticate posturing

- Hands and elbows flexed

- Ankles plantarflexed

- Shoulders adducted

Deceberate posturing

- Shoulders adducted

- Elbows extended

- Wrists pronated

- Hands flexed

- Ankles plantarflexed

What is meningitis?

inflammation of the meninges

What are the types of meningitis?

viral (aeseptic) and bacterial (septic)

What are the risk factors of meningitis?

- Viral meningitis

- Fungal meningitis

- Bacterial Meningitis

- Enviornment

What are the manifestions of meningitis?

- Headache

- Neck pain

- Nuchal rigidity (stiff neck

- Photophobia

- High fever

- Confusion/ ALOC

What are the nursing interventions for meningitis?

- ABC's

- Isolation

- Continuous monitoring

- Bedrest with HOB 30º

- Injury prevention

- Seizure precaution

- Administer medications

- IV ABX, anti-virals, antipyretics

What are abrupt, abnormal, excessive, and uncontrolled electrical discharges of reactions within the brain?

seizures

What are the risk factors for seizures?

- Genetic predispositions

- Acute febrile illness

- Head trauma

- Cerebral edema

- Infection

- Metabolic disorder

- Exposure to toxins

- Stroke

- Hypoxia

- Acute substance withdrawal

- Fluid and electrolyte imbalance

What are the manifestations for seizures?

- Jerking/ repetitive movements, stiffening

Loss of consciousness

- Changes in HR, breathing, sweating

- Confusion, drowsy, headache, muscle soreness

What are the priorities for seizures?

- Airway and preventing injury

- Do not leave patient alone

- Patient should be placed on the floor

- Remove clothing

- Place pillow or sheet under head

- Clear the area

- Do not restrain

-Pad and raise side rails

- Observe for damage to the tongue and oral mucosa

What is disruption in the cerebral blood flow secondary to ischemia, hemorrhage or embolism?

strokes (cerebrovascular accident

What are the types of strokes?

ischemic and hemorrhagic

Ischemic strokes?

caused by a blockage of circulation to the brain.

Hemorrhagic strokes?

occurs secondary to a ruptured artery or aneurysm

True or false: ischemic strokes are more common.

true

Risk factors for strokes?

- Cerebral aneurysm

- AV malformation

- Ethnicity

- Family Hx

- Age

- disease Hx

- smoking/alcohol/ substance abuse/ oral contraceptives

What are the manifestations for a stroke?

- Headache

- ALOC

- Hemiparesis

- Vision change

- Aphasia/ dysphagia

What do you assess for stroke?

- LOC and orientation

- Appearance

- Speech

- Motor function

- Gait

- Temperature

- Muscle tone

- Muscle strength

- Sensation

What are the priorites for stroke?

- ABC's

- Neuro checks and vitals

- Continuous telemetry monitoring

- HOB 30

- Seizure precautions

- Monitor blood glucose levels