Summary
Summary Nur 445 Critical Exam 3 Study Guide
- Course
- NUR 445
- Institution
- Indiana Wesleyan University
This is a comprehensive and detailed study guide on Exam 3 for Nur 445. *Essential!! *For Effective Exam Prep!!
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Chapters 17 & 18 Neuro Clinical Assessment
o Neurologic assessment
Early identification and treatment
KEY to successful healing
Labs and testing; objective info
Knowing what changes occur and how early we catch them
Change should be reported promptly
**LOC: first change seen for conscious pts…NEED to be reported
Unconscious pt: pupil change
Other medical conditions can affect clinical assessment
Get a good history: from birth up until current age
Respiratory issues
Increased CO2 or decreased O2
Medications
Sedatives, analgesics, benzos
History
o Neurologic history
Clinical manifestations
Frequent headaches
Dizziness
Vision changes
Muscle weakness
Muscle rigidity
Deep tendon reflexes (DTR’s)
Loss of sensation; numbness/tingling
Associated complaints
Precipitating factors
Was there an injury that caused this trauma?
Do they have the inability to move?
s/s leading up to this?
Progression
Familial occurrences
o Patient or family
Know if the info is accurately given by the consistency
When asked different questions, are they consistent with their answers?
Get a detailed report from pt or family
Get info from someone who has daily contact with the pt
Physical Examination
,o Level of consciousness
Evaluation of arousal
Appraisal of awareness
Looking at orientation x 3
Alert and oriented to person, place, time
Glasgow Coma Scale
Communication between neuro problems
Evaluates person’s LOC, orientation, neurological control of body on 3
different levels; eye opening, motor response, verbal response
***know the difference between following commands and reflexes
7 or less coma
d/t injury, medication
o Motor Function
Evaluation of muscle size and tone
Estimation of muscle strength
Out of 5: 5/5 is normal, 0/5 is no motor response
Abnormal motor responses
Decorticate: seen when have a higher level of flexion d/t lesion above
brainstem
Pull arms into “core”
, Decerebrate: lesion inside brain stem; extension; more severe injury
Combined: multiple levels of injury
Evaluation of reflexes
Deep tendon reflexes (DTRs)
Tell you where a level of injury might be
2+ is normal
0 is no response; be confident when giving this grading!!
Reflexes we had as infants that come back as an adult are
ABNORMAL (ex: grasp reflex, Babinski reflex)
Pupillary function
Eyes tell a lot about neurological function
Conscious, comatose
If pt is conscious, check ocular movements (PERRLA; see if they
have brisk or sluggish response to light)
If pt is unconscious, check oculocephalic using “doll eye
movement” test (you want pt to keep their eyes on the focus
point)
Control of eye movements
Oculomotor (CN III)
Trochlear (CN IV)
Abducens (CN VI)
Estimation of pupil size and shape
Check for direct and consensual size and response or pupils
Look at pupils and guess
Slim difference between the two is okay, significant ones are not
Oculocephalic test
Used in unconscious pts, not conscious pts
Brainstem takes over when consciousness is lost
Also called “doll’s eyed reflex”
Normal response for unconscious pt without brainstem damage:
pt should still be looking up when you turn their head bc brain
coordinates the movement in eyes
Abnormal response: one side is fixed and the other moves
Absent: when you turn the head, the eyes go with it
Assessment of eye movement
Oculovestibular reflex
Injection of iced cold water (20-30 mL)
HOB 30 degrees
Done by a provider!!
Normal: eyes shift towards stimulus (cold water)
Abnormal response (d/t swelling, trauma): eyes drift
opposite direction; may not be in sync
Sign of brainstem lesion or decrease in
brainstem function
, Absent response: no movement of eyes
**this test can cause severe nausea if pt is conscious
Respiratory Function
Observation of respiratory pattern
Normal: smooth, unlabored, even, consistent pattern
(12-24 breaths/min)
Changes are d/t cerebellar alterations
Evaluation of airway status
Swallow/gag reflex
Cheyne-Stokes breathing
Steady rise and fall of breath sounds (crescendo) then
period of apnea
KNOW Cheyne-stokes; affects upper brain stem and will
see abnormal breathing patterns
Cheyne stokes is typically end of life breathing
Cheyne stokes is upper brain while other breathing
patterns are from the brainstem
Central Neurogenic Hyperventilation
Breathing fast bc of injury to brain
No periods of apnea
Apneusis
Seen with stroke pts
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