Neuro IRAT: Neurological System Overview

What 5 activities does the nervous system control?

• motor

• sensory

• behavioral

• autonomic

• cognitive

What are the 2 components of the CNS?

• brain

• spinal cord

What is the PNS composed of?

peripheral nerve

What does the neurological assessment help identify?

• potential neurological dysfunction

What 2 problems does neurological dysfunction cause for the person?

inability to:

• perform ADLs

• have independent functioning

What must be established in a neurological assessment?

client’s baseline

What is the significance of comparing assessment findings?

to identify when changes are occurring

• changes are a cause for concern

What are the 5 key features of a full neurological assessment?

• GCS

• pupils

• motor function

• sensory function

• VS

What are the 3 components of GCS?

• eye opening

• motor response

• verbal response

What should the nurse do if GCS is < 8?

intubate patient

What is the priority for patients with extreme neurological dysfunction?

maintain the airway

Which response is recorded for GCS?

the best response

What does 3-8 points on GCS indicate?

severe brain injury

What does 9-12 points on GCS indicate?

moderate brain injury

What does 13-15 points on GCS indicate?

minor brain injury

Describe decorticate posturing

• pain response

• arms flexed to chest

What is decorticate positioning scored as?

3

Describe decerebrate positioning

• pain response

• arms extended

• fists clenched

What is decerebrate positioning score as?

2

What information does a pupillary assessment give?

• CNS function

• CN function

What could small pupils indicate?

medication (opioid) overdose

How is motor function assessed?

• is strength equal bilaterally?

• is movement equal bilaterally?

How is sensory function assessed?

sharp vs dull

What is a widening pulse?

greater difference between systolic & diastolic

What regulates temperature in the body?

hypothalamus

What are the 2 goals of nursing care r/t neuro?

• detect changes in cues

• minimize complications