Chapter 22 - Neurological and Mental Status Assessment

motor and sensory

(fill in the blank)

Patient who has a CVA in the right side of the brain will have ____ ___ ______ deficits on left side of body.

cerebrospinal fluid (CSF)

circulates within the space surrounding the brain, brainstem, and spinal cord, carries nutrients, allows for shifts of fluid between the brain and spinal cord

ascending tracts

carry specific sensory information from periphery to higher levels of CNS (skin, organs and muscles)

stereognosis

carry info about localized touch

proprioception

deep pressure, vibration, position sense

kinesthesia

movement

extrapyramidal tracts

controls gross automatic movements, such as reflexes, walking, complex movements, and postural control

deep tendon relfex

“knee-jerk” reaction when the patellar tendon is stimulated

superficial relfex

corneal, abdominal

visceral reflex

pupillary response to light

neonatal

rooting, grasp, Babinski

Glasgow Coma Scale (GCS)

GCS scores verbal response, eye opening, and motor function, if response verbally assess basic orientation which allows a basic speech/language assessment

risk factors for stroke

cigarette smoking, dyslipidemia, hypertension, diabetes mellitus, abdominal obesity, and psychosocial factors - modifiable by preventative measures and drug therapies

chronic neurological conditions

multiple sclerosis, Parkinson disease, Alzheimer disease, amyotrophic lateral sclerosis (ALS), Huntington disease, epilepsy

Call FAST alert

If any symptoms of stroke occur, _________.

last known well at (time)

If patient having stroke, what do you document immediately?

dysarthria

communication

cranial nerve testing

gag reflex (indicator for risk of aspiration), corneal reflexes

ataxia

unsteady, wavering movement with inability to touch the target; lack of coordination

cranial nerve ocular movement

sudden loss of vision happens, do not assess ______ bc they can’t see.

assessment of meningeal signs

nuchal rigidity (stiff neck), Brudzinski sign (resistance or pain in neck and flexion in hips or knees), Kernig sign (resistance to straitening or pain radiating down the posterior leg)

nuchal rigidity

stiff neck

brudzinski sign

resistance or pain in the neck and flexion in the hips or knees

kernig sign

resistance to straightening or pain radiating down the posterior leg