[Nursing II] Neurological & Neurovascular Assessment – Flashcards
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Assessing is something we do when?
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All the time.
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What are the five parts of a neurological exam?
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- Mental Status (do they give an appropriate response back when spoken to?). - Cranial nerves. - Motor function (grip tests, walking, gate, etc.). - Sensory Function. - Reflexes.
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What are the three parts of a mental assessment?
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- General appearance and behavior (are they dressed appropriate for the weather?). - Cognition (talks about donkeys and such instead of answering with an appropriate response). - Mood and Affect (Spouse has died, but they're acting giddy and happy. This is an altered affect.).
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When assessing motor system, what about the muscle are we hoping to assess?
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- Strength. - Tone. - Involuntary movements, symmetry of muscles.
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When assessing the motor system of a patient, what else should we assess about them that has to do with their gait/how they stand/and their mobility?
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We should assess their balance and coordination.
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When assessing the sensory system, what are some the main senses that we will be focusing on?
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The patient's sense of touch, pain, and temperature.
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What is a sense that relates to a person's standing?
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The standing sense/position sense is the awareness of the position of the body or its parts in space, a combination of the sense of equilibrium and kinesthesia.
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When checking reflexes, what are the two things we assess?
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The strength of response and symmetry of reflexes.
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When grading reflexes, what are the grades?
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4+ = Hyperactive. 3+ = Brisk, normal. 2+ = Normal. 1+ = Hypoactive. 0+ = None.
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What does the grading of the neurovascular system do for us?
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It evaluates the integrity of the peripheral nervous system and the adequacy of perfusion to the extremities.
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What are the three components of a neurovascular assessment?
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- Circulation. - Motor function. - Sensation.
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What are the subjective P's related to a neurovascular assessment?
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Pain and Paresthesias.
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What are the objective P's?
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Pallor (color). Polar (temp). Pulses. Perfusion (capillary refill). Paralysis (movement). Puffiness/Pitting (swelling/edema).
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What does a neurovascular assessment check for?
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It checks for peripheral nerve motor/sensory function.
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When performing a neurovascular assessment on the upper extremities, how do we check the radial/medial nerve for motor function?
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We have the patient dorsiflex their wrist. Motorcycle revving.
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When performing a neurovascular assessment on the upper extremities, how can we check their sensory abilities?
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Touch the web space between the thumb and index finger while the patient has their eyes closed.
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For the lower extremities, how do we check the motor abilities of the femoral nerve?
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Have the patient perform a straight leg raise.
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For the lower extremities, how do we check the sensory abilities of the femoral nerve?
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Stroke their anterior thigh while they have their eyes closed.
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When checking the peroneal nerve, who do we check their motor abilities?
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Have the patient dorsiflex their foot. This is when you lift up your toes towards your nose.
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How do we check sensory ability with the peroneal nerve?
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Touch the webbed space between the patient's large and second toe while patient has their eyes closed.
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To check tibial nerve motor function, what exercise can the patient do?
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They can plantar flex their foot. This is where their feet point straight down.
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How do we check the sensory ability of the tibial nerve?
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We touch the sole of the patient's foot while their eyes are closed.
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CARDIOVASCULAR ASSESSMENT
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...
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What are the two AV Valves?
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Tricuspid and Mitral Valve.
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What are the two semulunar valves?
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Pulmonic and Aortic valve.
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Systolic is normally what?
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95-140 mm/hg
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Diastolic?
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60-90 mm/hg
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What is the formula we use to find MAP (mean arterial pressure)? * Probably don't need to know this.
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Systolic BP + (Diastolic BP)x2, then divide this number by three. So, if a patient's BP is 83/50: 83 + 2(50) = 83 + 100 = 183. 183/3 = 61mm HG.
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MAP (mean arterial pressure) needs to be at least what?
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60
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Normally, is there a heart sound other than S1 and S2?
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No.
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What does it mean if you hear S3?
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It points to a ventricular gallop.
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What is the word that acts as mnemonic to help remember the rhythm that can be heard with an S3 gallop?
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Kentucky. It should be pronounced as: Ken Tuck Ee. Another popular mnemonic for this rhythm, and I swear I'm not making this up, is: F**k!... you're screwed. One beat... two beats.
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What does it mean if you hear S4?
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This is an atrial gallop.
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What is the word that acts as mnemonic to help remember the rhythm that can be heard with an S4 gallop?
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Tennessee. It should be pronounced as: Ten Nuh See. Once again, and I'm not making this up (YouTube it), an alternative is: Well f**k... you! Two beats... one beat.
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Murmurs are caused by what?
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A structural defect in a valve. Creates turbulence that occurs between normal heart sounds.
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What does a heart murmur sound like?
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Can be heard as a gentle blowing, swooshing sound.
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What can be said about the velocity of blood flow with a heart murmur?
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The velocity of the blood may increase such as when exercising. The velocity of the blood may decrease such as with patients who have anemia.
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What is a pericardial friction rub?
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A high pitched, scratching sound heard during s1 and/or s2.
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If a patient takes a deep breath and you can still hear a scratching sound at the heart, is this a pleural or pericardial friction rub?
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Pericardial.
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How does one get a pleural friction rub?
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Comes from pleural inflammation, from things like pleurisy, pneumonia, and pleural effusion.
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How is the pleural friction rub sound described as?
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A low pitch, grating quality.
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What symptoms could be experienced from a cardiovascular patient in terms of their energy levels?
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They might experience fatigue: No energy, needs more rest than usual.
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What is it that makes the sound in a pleural friction rub?
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Pleural surfaces rub together during respiration, upon inspiration and expiration. It is painful.
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What symptoms could be experienced from a cardiovascular patient in terms of their weight?
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They could experience fluid retention: weight gain; tightening of clothing; shoes no longer fitting; indentations left on garments.
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What symptoms could be experienced from a cardiovascular patient in terms of their heartbeat?
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They could experience an irregular heartbeat: the feeling of their "heart in their throat"; could experience palpitations.
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What symptoms might a patient with cardiovascular issues have with their breathing?
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Dyspnea: SOB; air hunger; orthopnea.
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What symptoms might a patient have in terms of pain when dealing with cardiovascular issues?
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Indigestion, burning, numbness, tightness (I assume in chest), substernal pain radiating to shoulder, pain in the neck, arms, and jaws.
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What sort of symptoms could be seen in the legs of a cardiovascular patient?
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Tenderness in calf or leg-distended, discolored.
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What symptom could be expected of a cardiovascular patient that might make them a fall-risk?
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They could experience syncope.
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When dealing with a cardiovascular patient, what eight pieces of subjective data would be nice to gather from a patient?
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- Patient's health history. - Medications: including OTC and herbal supplements. - Surgery or other previous treatments. - Risk factors, such as smoking. - Ask about allergies. - Ask about diet. - Ask about weight today versus weight on year ago. - Ask if eating causes SOB.
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When dealing with a cardiovascular patient, what two types of assessments might we do?
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- Vital signs. - Orthostatic (postural) BPs should be measured while the patient is lying, sitting and standing. Normally there is a reduction of 11mm Hg in the SBP and 3mm Hg DBP.
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When performing an inspection of a patient in relation to the peripheral vascular system, what are some things we should look for?
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- Skin color. - Hair distribution. - Venous patterns. - Edema. - Thrombophlebitis. - Clubbing of nail beds. - Prominent pulsations of the neck veins. - Jugular vein distention (JvD).
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Where is the angle of louis located? And what is the angle of louis helpful in doing?
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The angle of louis is at the level of the 2nd rib, useful place to count ICS (APETM).
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When listening to heart sounds, where can we find the aortic area?
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At the 2nd ICS (intercostal space) to the right of the patient's sternum. This is the only heart sound found on the patient's right hand side.
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When listening to heart sounds, where can we find the pulmonic area?
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At the 2nd ICS to left of the sternum.
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When listening to heart sounds, where can we find Erb's point?
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At the 3rd left ICS, near the sternum.
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When listening to heart sounds, where can we find the tricuspid area?
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At the 5th left ICS, close to sternum.
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When listening to heart sounds, where can we find the mitral area?
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At the left midclavicular line in the 5th ICS.
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What does APETM stand for?
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- Aortic. - Pulmonic. - Erb's Point. - Tricuspid. - Mitral.
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What is a bruit?
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A buzzing or humming sound caused by an abnormal flow; ex. an artery that has a narrow or bulging wall.
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Where can we auscultate to best hear a bruit?
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Auscultate carotid arteries, abdominal aorta, and and femoral arteries.
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Where do we never palpate with two hands?
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On the carotid, dog.
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Where are the peripheral areas where we can get a pulse?
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- Carotid. - Brachial. - Radial. - Ulnar. - Femoral. - Popliteal. - Posterior Tibial. - Dorsalis Pedis.
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When palpating, going just off of how it feels to us (not focusing on how hard the beat is), what should we note about an artery/vessel?
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The rigidity (hardness) of the vessel should be noted.
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What is a "thrill"?
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A normal pulse will feel like a tap, whereas a vessel that is narrowed or bulging will vibrate and this is what is called a "thrill."
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When looking at how age affects the cardiovascular system, what are some changes that we see in this system?
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- The amount of collagen in the heart increases and elastin decreases. - Cardiac valves are thicker from lipid accumulation. - The number of pacemaker cells in the SA Node becomes decreased. - Pulse pressure widens.
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Just because a patient is old, does that mean they'll have high blood pressure?
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No.
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When inspecting a patient with cardiovascular issues, what are some "good signs" that we look for?
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- Normal skin color. - Capillary refill < 3 sec. - Thorax symmettric. - PMI not visible. - No JVD with patient @ 45 degree angle.
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Why is the left ventricle thicker than the right.
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It is the systemic pump for our system.
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OXYGENATION RESPIRATORY ASSESSMENT
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...
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The primary function of the resp exchange is what?
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Gas exchange.
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What are the two big things that happen within the lungs?
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Ventilation and diffusion.
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What is ventilation?
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The movement of air between the environment and the lungs.
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1) What is diffusion? 2) And what two tests measure the efficiency of diffusion?
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1) Oxygen & CO2 movement across capillary membrane. 2) Efficiency measured by: ABG's and Pulse Oximetry.
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When looking at ventillation, is respiration considered to be active or passive?
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ACTIVE. The passing of air into lungs is something we tell the body to do (skipped over a lot of this in class).
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When looking at ventillation, is expiration considered to be active or passive?
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PASSIVE. The movement of air out of lungs is something we do involuntary (skipped over a lot of this in class).
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When looking at ventilation, what three qualities should we take notes on when listening to lung sounds?
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Rate, rhythm, and pattern.
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Is ventillation considered internal or external respiration? Is diffusion is considered internal or external respiration?
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Ventillation is external. Diffusion is internal. Gas exchange in the lungs is referred to as external respiration as one side of the respiratory membrane - that is, the alveolar air - is actually outside of the body. Diffusion is all on the inside of the body.
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Where in the brain can we find the respiratory center?
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In the medulla.
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What two cell bodies control most of the actions of the respiratory system?
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Chemoreceptors in the medulla and carotid bodies.
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What does the skin of a patient with respiratory problems often look like?
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Pale, blue.
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What types of complaints are expected when it comes to the breathing of a person experiencing respiratory problems?
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SOB, difficulty breathing.
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What can we physically inspect on a patient in order to determine respiratory problems?
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Their skin, and capillary refell.
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What type of movement should we see in the posterior thorax?
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The posterior thorax should move evenly.
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Where can bronchial sounds be heard?
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Over large airways like the trachea and manubrium (the broad upper part of the sternum).
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When listening to bronchial sounds, how are they often described? What can be said about inspiration vs. expiration with bronchial sounds?
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- Hitch pitch, loud sounds. There's a short pause between inspiration & expiration. - I < E (2:3) - expiratory sounds last longer than inspiratory sounds.
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Where can Bronchovesicular sounds often be heard?
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At the 2nd/3rd ICS. Between Scapulae.
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When looking at bronchovesicular sounds, how are they described? And what can be said about inspiration vs. expiration with bronchial sounds?
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- Softer than bronchial sounds, tubular quality. Mainstem Bronchi. - Inspiration is equal to expiration (1:1).
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When looking at vesicular sounds, what can be said about their inspiration to expiration ratio?
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Inspiration > expiration (3:1)
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What are adventitious breath sounds?
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Extra or additional sounds that are heard over normal breath sounds.
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Are adventitious breath sounds considered to be "abnormal breath sounds"?
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No, they are different than "abnormal breath sounds".
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What are "abnormal breath sounds"?
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These are sounds heard in areas where they are not normally heard.
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What are six examples of adventious breath sounds?
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- Crackles (fine or coarse). - Pleural friction rub. - Rhonchi (snoring sound). - Wheezes. - Stridor (an abnormal, high-pitched, musical breathing sound caused by a blockage in the throat or voice box). - Absent breath sounds.
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What are six expectations regarding an aging patient and their breathing?
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- Decreased chest wall compliance and stiff chest. - The AP diameter is increased, chest appears barrel-shaped. - May use accessory muscles when breathing. - Decreased functional alveoli & elastin, less tolerant for exertion. - Less forceful cough & less cilia. - More gradual response to changes in blood oxygen or carbon dioxide level.
