Summary Nur 445 Critical Exam 3 Study Guide

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