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!!
[Show more]
Content preview
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
The benefits of buying summaries with Stuvia:
Guaranteed quality through customer reviews
Stuvia customers have reviewed more than 700,000 summaries. This how you know that you are buying the best documents.
Quick and easy check-out
You can quickly pay through credit card or Stuvia-credit for the summaries. There is no membership needed.
Focus on what matters
Your fellow students write the study notes themselves, which is why the documents are always reliable and up-to-date. This ensures you quickly get to the core!
Frequently asked questions
What do I get when I buy this document?
You get a PDF, available immediately after your purchase. The purchased document is accessible anytime, anywhere and indefinitely through your profile.
Satisfaction guarantee: how does it work?
Our satisfaction guarantee ensures that you always find a study document that suits you well. You fill out a form, and our customer service team takes care of the rest.
Who am I buying these notes from?
Stuvia is a marketplace, so you are not buying this document from us, but from seller anyiamgeorge19. Stuvia facilitates payment to the seller.
Will I be stuck with a subscription?
No, you only buy these notes for $14.99. You're not tied to anything after your purchase.
Can Stuvia be trusted?
4.6 stars on Google & Trustpilot (+1000 reviews)
62555 documents were sold in the last 30 days
Founded in 2010, the go-to place to buy study notes for 14 years now