Neurological Assessment includes - ✔✔ -client's current condition
-Glasgow Coma Scale
-pupillary changes
-hand grips/leg lifts/pushing strength
... [Show More] of feet
-Babinski reflex
Neurological Assessment of Client's Current Condition - Onset: It's important to know - ✔✔ when the symptoms started
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
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)
Neurological Assessment - Babinski Reflex: What does it mean if the adult has a Babinski reflex or fanning of the toes when you stroke the bottom of the foot? - ✔✔ there is a severe problem in the CNS that is affecting an upper motor neuron
Neurological Assessment - Babinski Reflex: Possible causes of a Babinski reflex in an adult - ✔✔ -tumor or lesion on the brain or spinal cord
-meningitis
-multiple sclerosis
-Lou Gehrig's disease
Neurological Assessment - Deep Tendon Reflex Scale: 0 is - ✔✔ no response (absent)
Neurological Assessment - Deep Tendon Reflex Scale: 1+ is - ✔✔ present, but sluggish or diminished (hypoactive)
Neurological Assessment - Deep Tendon Reflex Scale: 2+ is - ✔✔ active or expected response (normal) [Show Less]