-
health history
- family history
- headaches (look for changes)
- clumsiness
- loss of function, numbness, tingling, pain in an extremity
- visual acuity / double vision
- seizures (new, different)
- personality changes / mood swings
- fatigue / tireness
- trauma in last 6 months
- speech, reasoning, movement, intellect changes
-
mental status
- orientation
- mood / behavior
- general knowledge of well known facts
- short & long term memory
- attention span / ability to concentrate
-
eyes
- PERRLA
- accomodation: place finger 6" from nose, bring closer, eyes should coverge/pupils constrict
- ptsosis: drooping lids
- nystagmus: rapid back and forth motion
-
LOC
- irritibility
- personality changes
- restlessness
- short term memory
- disorientation to time > place > person
- confusion
-
Glasgow Coma Scale
- assess eye opening, verbal response, motor response
- Score 3 - 15
- < 8 = coma
- 9 - 12 = moderate
- 13 - 14 = mild
-
GCS - eye opening
- spontaneously - 4
- to speech - 3
- to pain - 2
- none - 1
-
GCS - verbal response
- oriented - 5
- confused - 4
- inappropriate - 3
- incomprehensible - 2
- none - 1
-
GCS - motor response
- obeys commands - 6
- localizes to pain - 5
- withdraws from pain - 4
- flexion to pain - 3
- extension to pain - 2
- none - 1
-
awake and alert
responds appropriately to auditory, tactile, visual stimuli
-
disoriented
- unaware of time > place > person
- unable to follow simple commands
- slowed thinking
- inattentive
- flat affect
- easily bewildered
- agitated, restless, irritable
- high risk for injury
-
delirium
- sudden severe confusion and rapid changes in brainfunction that occur with physical or mental illness
- motor restlessness
- agitated
- irritible
- combative
-
somnolent / lethargic / obtunded
- drowsy/sleepy
- oriented but sluggish
- delayed responses to questions
- responds to painful stimuli
-
stupor
- aroused only with visual stimulation
- response to pain
- slow/sluggish speech, movement, thought processes
-
coma
- sleeplike state
- does not respond to painful stimuli
- no verbal sounds
- no cough or gag reflex - aspiration risk - airway
- incontinent
- irregular respirations
-
aphasia
- defective/absent lanugage function
- language is primarily left hemisphere
- speech, reading, writing, understanding
-
expressive aphasia
- loss of the ability to produce language
- caused by damage to Broca's area
-
receptive aphasia
- inability to comprehend language or speak with appropriately meaningful
- words
- caused by damage to Wernicke's area
-
global aphasia
both expressive and receptive
-
anomia
inability to recall words or names
-
dysarthria
difficult/poor articulated speech due to poor muscle control
-
muscle function
- most commonly encountered neuro symptom
- assess gait, stance, muscle tone, coordination, involuntary movement, stretch reflexes, hand grasps, foot pushes, arm drift
- compare one side to other, assess in pairs (symmetry)
-
spasticity / flaccidity
- spasticity: muscles have sudden movement
- flaccidity: muscles are weak and flabby
-
Babinski's reflex
- normal: flexion of great toe (negative Babinski's)
- abnormal: extension of the great toe (positive Babinski's)
reversed for infants < 6 months
-
Romberg's test
- pt stands feet together / eyes closed
- negative Romberg: minimal swaying
- positive Romberg: leans/sways to one side
- may indicate cerebellar dysfunction
-
paralysis
- paralysis: loss of function
- paresis: weakness (anything less than total loss)
- flaccid paralysis: weak, soft, flabby muscle tone
- spastic paralyis: involuntary sudden movements or muscle contractions
- fasiculations: small, involuntary, spontanous muscle contractions
- clonus: alterating contraction/relaxation of muscle
-
sensory / perceptual status
- assess response to pain, touch, temp
- proprioception: sensation pertaining spatial position, muscular activity
-
unilateral neglect
pt is perceptually unaware of and inattentive to one side of the body
-
hemianopia
blindness in half of visual field
-
vital signs
- temperature
- BP - widening pulse pressure can indicate increased ICP
-
blood and urine tests
- urine - diabetes insipidus, rule out drug use
- ABGs - O2 concentrations
- routine blood tests
-
CSF test
- normal CSF - 10 lymphocytes/ml ( > indicates infection)
- C&S
- --TB or viral infections
- --bacterial infections may decrease glucose/chloride levels
- Elevated protein - degenerative disease, brain tumor
- Blood - hemorrhage
-
CT
- detects pathologic conditions of brain / spinal cord
- shows areas with increased densities (tumors/thrombi)
- no radioisotopes
- no special prep
- 60 mins w/contrast medium - 30 mins without
-
brain scan
- uses radioisotopes - injected several hours before scan
- shows concentrated areas
- no special prep
- 45 mins
-
PET scan
- radioactive glucose injected
- color composite picture is obtained
- shades of color indicate levels of glucose metabolism
- used for stroke, alzheimer's, parkinson's, epilepsy
-
lumbar puncture
- used to obtain CSF sample, relieve pressure, inject dye/meds
- contraindicated for ^ ICP (causes brain herniation)
- lie flat after test
- monitor dressing for bleeding/CSF leakage
-
electroencephalography (EEG)
- measures electrical activity of brain
- dx epilepsy, lesions, brain injury
- electrical patches attached to scalp
-
myelogram
- x-ray w/ contrast medium to visualize spine
- dx lesions in spinal canal, herniated disks, bone deformities
- measure baseline LE strength and sensation pre-test
- similar to lumbar puncture
-
cerebral arteriogram
- x-ray w/ contrast medium of blood vessels in the brain
- dx aneurysms, vessel anomalies, ruptured vessels, displacement of vessels by tumors/masses
- pre-test - assess pedal pulses (femoral approach), neck circumfrence (carotid approach)
- post-test - monitor site for hematomas, LOC, pedal pulses/neck circumfrence
- ^ risk for ^ ICP, stroke
-
carotid duplex
- evaluates carotid occlusion
- non-invasive
- used for TIAs
-
electromyogram (EMG)
- measures contraction of muscles in response to electrical stimulation
- clarifies muscle vs. neuro problems
- post-test - rest and analgesics
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