HURST Review: Neuro

Neurological Assessment includes -client's current condition -Glasgow Coma Scale -pupillary changes -hand grips/leg lifts/pushing strength of feet -Babinski reflex Neurological Assessment of Client's Current Condition - Onset: It's important to know when the symptoms started 01:06 01:34 Neurological Assessment of Client's Current Condition - Onset: Ask them _______________________________ and what ____________________________ when was the onset; symptoms did the client have intially Neurological Assessment of Client's Current Condition - Description of Symptoms: Have them describe Neurological Assessment of Client's Current Condition - Description of Symptoms: Know the ________________, how __________________________, and how _______________ location; long the symptoms have persisted; severe Neurological Assessment of Client's Current Condition - Associated Factors: Determine if there were any __________________________________ associated with the symptoms triggers or aggravating factors Neurological Assessment of Client's Current Condition - Associated Factors: Ask them "did anything ________________________ the symptoms?" help relieve Neurological Assessment of Client's Current Condition - Overall Appearance: Note the client's general appearance and behavior Neurological Assessment of Client's Current Condition - Overall Appearance: Observe if there are any ______________________________ of a ____________________________ deficit? obvious signs; neurological (speech slur? drooping side of face?) Neurological Assessment of Client's Current Condition - Degree of Consciousness: What is the MOST important aspect of the neuro exam? assessment of the client's mental status, including LOC Neurological Assessment of Client's Current Condition - Degree of Consciousness: Mental status includes -awareness of surroundings and alertness -orientation to person, place, and time -memory: both short-term and long-term Neurological Assessment of Client's Current Condition - Degree of Consciousness: The most sensitive indicator of neuro status is LOC 00:01 01:34 Neurological Assessment of Client's Current Condition - Degree of Consciousness: A change in LOC may be the first sign that there is a problem Neurological Assessment - Glasgow Coma Scale: This scale is used to assess the LOC in a client who already has altered consciousness or has the potential of altered consciousness Neurological Assessment - Glasgow Coma Scale: This scale is used primarily in the ED or ICU Neurological Assessment - Glasgow Coma Scale: The definition of this scale is a scale that measures the degree of LOC Neurological Assessment - Glasgow Coma Scale: 3 responses of this scale 1. eye opening 2. motor response 3. verbal response Neurological Assessment - Glasgow Coma Scale: RULE - we like a high number ranging from 13 to 15 Neurological Assessment - Glasgow Coma Scale: What is always #1 with neurological assessment? LOC Neurological Assessment - Glasgow Coma Scale: Eye Opening (E) scores 4 - spontaneous 3 - to verbal command 2 - to pain 1 - no response Neurological Assessment - Glasgow Coma Scale: Motor Response (M) scores 6 - to verbal command 5 - to localized pain 4 - flexed/withdraws 3 - flexes abnormally 2 - extends abnormally 1 - no response Neurological Assessment - Glasgow Coma Scale: Verbal Response (V) scores 5 - oriented/talks 4 - disoriented/talks 3 - inappropriate words 2 - incomprehensible sounds 1 - no response Neurological Assessment - Glasgow Coma Scale: The total score is determined using what formula? E + M + V Neurological Assessment - Pupillary changes: Determined using PERRLA Neurological Assessment - Pupillary changes: Normal pupil size 2-6 mm Neurological Assessment - Hand Grips/Leg Lifts/Pushing Strength of Feet: This is assessed for strength and equality and if client will follow a command Neurological Assessment - Babinski Reflex: Normal in an infant up to 1 year Neurological Assessment - Babinski Reflex: Though it is normal in an infant up to 1 year, it may be seen up to 2 years (should disappear when walking starts) Neurological Assessment - Babinski Reflex: Abnormal in an adult Neurological Assessment - Babinski Reflex: The adult or child greater than 1 year should have a normal reflex or ____________________________ when the bottom of the foot is stroked curling of the toes (Plantar Reflex)