Sensorimotor exam #3
If a patient has a motor response that shows no response, what score would you give them for best motor response on the Glasgow coma scale?
1
If a patient has no eye opening response, what score would you give them for eye opening response on the Glasgow coma scale?
1
If a patient has no verbal response, what score would you give them for best verbal response on the Glasgow coma scale?
1
What are the symptoms of increased intracranial pressure?
Headache, nausea, vomiting, blurred vision, changes in behavior, lethargy to coma, change I. Speech pattern, aphasia, pupillary changes (papilledema), cranial nerve dysfunction, seizures, abnormal posturing, cushings triad, changes in vital signs
How is increased intracranial pressure diagnosed?
History and physical, CT, neurochecks (obtain accurate baseline prior to), ABGs
What are the main things that are included in a neuro assessment?
History, mental status, cranial nerve function, motor function, cerebellar exam, sensory function, reflexes, and speech
What is the bicep reflex?
Hit the biceps brachii tendon at the elbow
What is cranial nerve XII?
Hypoglossal (controls most of the tongue movements, important for speech and swallowing)
What is receptive aphasia?
Inability to comprehend spoken words
What is expressive aphasia?
Inability to express self using motor aspects of speech
What can be the cause of increased cranial pressure?
Increase in brain tissue, vascular tissue, and volume of cerebrospinal fluid, or as increase in cranial cavity
What is the leading cause of death from head injury in those who reach the hospital
Increased intracranial pressure
What is disarthria?
Ineffective articulation of speech
What needs to be signed before a cerebral angiography?
Informed consent, make sure patient understands the procedure
How does decadron (dexamethasone) help treat increased intracranial pressure
It is given IV, and is a corticosteroid that helps reduce inflammation
How does Dilantin (phenytoin) help treat increased intracranial pressure?
It is given during a seizure that can occur as a result of IICP
How long should the babinski reflex be present?
It is normal for the toes to fan out in infants up to 6 months
What does decerebrate posturing indicate?
Lesions at the level of the brain stem, very grave prognosis
How would you assess motor functioning when performing a neuro assessment?
Look at muscle tone, movement, and strength, compare right and left sides for equality and symmetry, and look for any twitching or tremors
What test should never be done to diagnose increased intracranial pressure?
Lumbar puncture, it can cause a sudden and rapid decrease in intracranial pressure and the sudden change in volume can lead to herniation
What medications should you avoid when caring for a patient with increased intracranial pressure?
Narcotics or meds that could cause respiratory depression
What is global aphasia?
Neither express or comprehend language
What is cranial nerve III
Oculomotor (eye movement)
What is cranial nerve I
Olfactory (smell)
What is cranial nerve II
Optic (vision)
What are the things that might be altered when assessing a patients mental status during a neuro exam?
Orientation, level of consciousness, appearance, behavior, mood, speech pattern, thought processes, memory, language, thinking things differently than they used to
What are the other reflexes to check during a neurological exam?
Patellar, Achilles, bicep
If increased ICP is caused by too much CSF or hemorrhage, what can they do to fix it?
Puncture of the ventricle of the brain to aspirate CSF with a needle, or continuous drainage by a ventriculostomy tube
What is a craniectomy?
Removing a piece of the skull to allow the brain to expand (treats IICP)
What should you do for a patient after they have a cerebral angiography?
Restrict movement, monitor vascular status, VS, intake and output, assess insertion site, check peripheral pulses (due to femoral artery use)
What is the Glasgow Coma Scale?
Scale used to test arousal of patient, for patients who have suffered a traumatic brain injury, measures the level of consciousness of a patient
What is the possible range of scores in the Glasgow coma scale?
Scores range from 3-15
If the cause of increased intracranial pressure is a tumor, how can it be managed medically?
Surgery
How would vitals signs change with increased intracranial pressure?
Temperature and blood pressure would be increased while pulse and respirations would be decreased
What artery is the dye injected into for a cerebral angiography?
The femoral artery
What is the patellar reflex?
The patellar reflex is the kicking movement of the lower leg in response to a sharp tap on the patellar tendon.
What is an abnormal result of the babinski reflex test?
The toes fanning out
What is a normal result of the babinski reflex test?
The toes would curl
What should you remember about medications that are used to treat increased intracranial pressure?
They all dehydrate and put excess fluid into the circulation. Serum osmolality and electrolytes should be monitored
What is cerebral angiography used for?
To view the vascular structure of the brain, and is used to assess the cause of strokes, seizures, headaches, and motor weakness
What can cause increased intracranial pressure?
Too much CSF, swelling of the brain, aneurysm, brain or head injury, brain tumor, infection (meningitis, encephalitis), hydrocephalus, high blood pressure, stroke
How is cerebellar exam done?
Touch nose with finger, thumb to finger test
What is cranial nerve V?
Trigeminal (facial sensation and movement)
What is cranial nerve IV?
Trochlear (eye movement)
What is the gold standard medication for increased intracranial pressure?
Urea IV
What medications can be used to treat increased intracranial pressure?
Urea, mannitol, hypertonic glucose, decadron (dexamethasone), Dilantin
What is cranial nerve X?
Vagus (controls muscle of voice, innervates many organs, can cause lowering of the heart rate, and muscle movement)
What is cranial Nerve VIII?
Vestibulocochlear (hearing and balance)
What is the Babinski reflex?
When stroking the sole of the foot causes toes to either fan out or curl up
How is sensory function tested during a neurological exam?
With eyes closed, touch with sharp/dull objects, identify objects when placed in hand
If the increased intracranial pressure is due to swelling, how can it be treated?
With medications
Can decorticate and decerebrate posturing occur concurrently?
Yes, there can be one on each side and it will be accompanied by deep coma, rapid breathing, and dilated pupils
If a patient has a verbal response that shows they are alert to time, place, and person, what score would you give them for best verbal response on the Glasgow coma scale?
5
If a patient has a motor response that shows they can obey commands, what score would you give them for best motor response on the Glasgow coma scale?
6
What score in the Glasgow coma scale would indicate comatose
7 or less
What is the normal intracranial pressure?
10-15 mmhg
What is the best score for the Glasgow coma scale?
15
If a patient has a motor response that shows abnormal extension (decerebrate), what score would you give them for best motor response on the Glasgow coma scale?
2
If a patient has a verbal response that is incomprehensible sounds, what score would you give them for best verbal response on the Glasgow coma scale?
2
If a patient has an eye opening response to pain, what score would you give them for eye opening response on the Glasgow coma scale?
2
If a patient has a motor response that shows abnormal flexion (decorticate) what score would you give them for best motor response on the Glasgow coma scale?
3
If a patient has a verbal response with inappropriate word, what score would you give them for best verbal response on the Glasgow coma scale?
3
If a patient has an eye opening response to speech, what score would you give them for eye opening response on the Glasgow coma scale?
3
What is the worst score for the Glasgow coma scale?
3
What score in the Glasgow coma scale would indicate that a patient is brain dead?
3
If a patient has a motor response that shows flexion withdrawal from pain, what score would you give them for best motor response on the Glasgow coma scale?
4
If a patient has a spontaneous eye opening response, what score would you give them for eye opening response on the Glasgow coma scale?
4
If a patient has a verbal response that shows they are confused, what score would you give them for best verbal response on the Glasgow coma scale?
4
How long should a patient be NPO before a cerebral angiography
4-6 hours
If a patient has a motor response that shows they move to localized pain, what score would you give them for best motor response on the Glasgow coma scale?
5
How is intracranial pressure continuously monitored?
A catheter is inserted by a neurosurgeon and a transducer converts intracranial pressure to electrical impulses for constant monitoring
What does decorticate posturing indicate?
A lesion that involves a large portion of the sensorimotor cortex
What is cranial nerve VI?
Abducens (eye movement)
What is decorticate posturing?
Abnormal Flexion of the arm and legs pulled toward the core of the body.
What is decerebrate posturing?
Abnormal body posture involves the arms and legs being extended straight out, the total is being pointed downward, and the head and neck being arched backwards.
What is cranial nerve XI?
Accessory (controls movements of the neck and shoulders)
What should you know about the patient before they have cerebral angiography done?
Allergy to contrast dye, if they're taking anticoagulants, and if their renal function is good
What causes abnormal posturing?
Any damage to the CNS can lead to pathological motor responses in comatose patients
What level is considered to be an increase in intracranial pressure?
Anything over 15mmhg
What is the purpose of the cerebella exam?
Assess balance and coordination and gait
How would you assess the proper functioning of cranial nerves during a neuro assessment?
Assess swallowing, shoulder shrug, hearing, etc
What is the priority intervention for a patient who is comatose according to the Glasgow coma scale?
Assessment of airway, breathing, and circulation
Why is it important to know renal function before a cerebral angiography?
Because contrast dye is used, and the kidneys need to be working well in order to be able to excrete them dye
How does hypertonic glucose help treat increased intracranial pressure?
Given IV (25-50%) as head injury can cause increased cerebral metabolic rate of glucose
How does mannitol help treat increased intracranial pressure?
Given IV, it is a diuretic that reduces edema and pressure inside the eye and brain
How does urea help treat increased intracranial pressure?
Given IV, it is an osmotic diuretic.
If a patients eyes are swollen, and they can't open them, how would you score the eye opening category on the Glasgow coma scale?
Can't evaluate eye opening with swollen eyes, give a 1 and make a note
If a patient is on a vent or they have facial trauma and can't speak, how would you evaluate verbal response on the Glasgow coma scale?
Can't evaluate, give a score of 1 and make a note
What should you be looking for when assessing reflexes in the neuro assessment?
Check for hypo and hyper reflexes as well as symmetrical or asymmetrical reflexes
What would be included in the history section of a neurological assessment?
Circumstances of injury on admission, family and social history, chief complaint and symptoms, past medical history, medications, vision and hearing, ADLs, drug use, how problem was treated
What is cerebral angiography?
Contras dye is used to examine the blood vessels within the head and neck. It is an X Ray of cerebral circulation.
What would temporarily cause increased intracranial pressure?
Cough, sneeze, straining with BM (valsalva), contrast dye with CT or angiography can irritate The cerebral blood vessels causing temporary increased intracranial pressure
What is cranial nerve IX?
Glossopharyngeal (sense taste and responsible for gag reflex)
What is behind the pathology of increased intracranial pressure?
Decreased cerebral blood flow leading to increased pCO2 and decreased O2 which triggers vasodilation and cerebral edema, which increased intracranial pressure
How is increased ICP treated?
Depending on the cause
What things might be included in the past medical history of a patient who is having a neurological assessment?
Diagnoses such as HTN, CAD, seizures, and other things like alcohol use, smoking, history of falls or accidents, and surgeries
What is Cushing's triad?
Elevated BP, decreased pulse, decreased respirations
What is cranial nerve VII?
Facial (facial movement and sensing taste)
What is the achilles reflex?
Foot is dorsiflexed at ankle and hammer strikes stretched Achilles' tendon, plantar flexion occurs
What does IICP stand for?
increased intracranial pressure