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Summary NUR 170 - Exam 2 Study Guide.
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NUR 170 EXAM 2 REVIEWAssessment of the Nervous System –Ch. 41
Neuro Assessment—Medical hx- pg. 846 Chart 41-2
Evaluation of Mental Status— establishment of patient's norm regarding mental status
o Consciousness: the ability to be aware of the environment, an object, & oneself; LOC—
degree of alertness or amount of stimulation needed to engage in a patient's attention;
Alert: awake, engaged, & responsive (not oriented to person, place, or time) less
than alert is lethargic, drowsy but responsive; stuporous, arousable only with
vigorous or painful stimulation.
Coma: unconscious & cannot be aroused despite vigorous or noxious
stimulation.
o Cognition: evaluated in a rapid or focused manner using tests of memory & attention
that require verbal or written ability. Three types of memory can be tested: long-term
(remote), recall (recent), & immediate.
Mobility and Motor System Function—Range, strength, posture, abnormal movements, PERRLA
Report all decreases to the primary health care provider
Deep Tendon Reflexes and Sensation—Pain, touch, temp, vibration, position
Cerebellar Function—Gait, balance, coordination.
,Rapid Neuro Assessment—
NIHSS (National Institute of Health Stroke Scale)
o Critical focused assessment that gives quick and reliable information on the neuro status
of the patient.
GCS Establishes baseline data:
Highest score is 15
Critical Rescue—A decrease in 2 points or more in the GCS is clinically significant
and MD must be notified!
, Diagnostic's—
Cerebral Angiography- visualize cerebral circulation to detect blockages in arteries or veins in
brain, head, or neck. Catheter is placed in groin to inject dye.
o Patients must sign consent
o Detailed hx obtained:
Renal disease
Heart Failure
Dehydration
Older Age
o Rx- such as Metformin or NSAIDS (reduce renal perfusion) Contrast media w/i the last 72
hrs. STOP Metformin 48 hrs. before
o Must know kidney function labs prior to test
o Allergies (Ch. 41-3 p. 852)—multiple food allergies or asthma; suspected contrast
sensitivity is pre-treated with steroids.
o Pt. Education:
Patient is awake, head immobilized, and no not move during procedure.
Patients may feel a hot or warm sensation when dye is injected—that is normal.
Computed Tomography (CT)- pictures are taken showing “slices” of different levels of the brain
or spinal cord. Best way to see bones.
o Very accurate, quick, painless, least expensive imaging method. Same evaluation for
Cerebral Angio is completed prior to test
o Pt. Education-
inform patient that they may feel a warm or cool sensation after dye is injected.
May also have a metallic taste.
Magnetic Resonance Imaging (MRI)-Magnetic fields are used to obtain images to determine
abnormal and normal anatomy. Images can be more detailed to assist with proper diagnosis of
condition. Such as, abnormalities in any part of the body that is particularly scanned to blood
flow and tissues involved.
o Prep—
Same information obtained from patient as CA and CT—consent must be signed
NO METAL may enter the imaging room—patient or medical personal.
Contraindicated with patients w/ older tattoos (contain lead), confused/agitated,
have unstable vitals, or on life support.
o Contrast can also be used—requires normal kidney function.
Watch cardiac function especially in patients who have cardiac pacemakers,
other implanted pumps or devices, and ion containing metal aneurysm clips.
Lumbar Puncture (spinal tap)- The insertion of a spinal needle into the subarachnoid space
between the third and fourth (sometimes fourth and fifth) lumbar vertebrae.
LP used for spinal anesthetics—labor
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