Neurological assessment

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  • Created by: evepoag
  • Created on: 19-05-22 09:46
How can you initially assess neurological condition?
AVPU assessment
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What does AVPU stand for?
Alert
Voice
Pain
Unresponsive
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If concerned, how you can you further assess neurological condition?
The Glasgow coma scale
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What are the 3 components of the GCS?
Eyes
Verbal
Motor
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What are the 4 steps when completing the GCS assessment?
1. check
2. observe
3. stimulate
4. rate
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In the first check stage, what are you looking for?
Hearing impairments, drugs administered
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What is the reason for the CHECK stage at the start?
To identify any factors that may affect the assessment
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In the observe stage, what are you observing?
Any spontaneous behaviour in the 3 areas (eyes, verbal, motor)
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What is the lowest criteria for each of the 3 components?
No response
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How can you apply a peripheral pain stimulus safely?
Press on nail bed with increasing intensity for 10 seconds
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What are two methods of central pain stimulus?
1. The trapezius pinch
2. pressure to the supraorbital ridge
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When would you use the supraorbital ridge pressure?
If there has been no response from the trapezius pinch after 10 seconds
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What is the difference between normal and abnormal flexion?
In normal flexion, elbow bends and arm moves rapidly away from the body and stimulus

In abnormal flexion, elbow bends slowly and the arm comes inward across the body
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If a patient extends their arm, instead of flexing, what should be recorded?
Extension
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If the right and left responses are different, which should you record?
record the better side response
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How many criteria is there in eyes, verbal, motor assessment?
Eyes - 4
Verbal - 5
Motor - 6
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What is the sequence of responses, when assessing eyes?
Spontaneous, to sound, to pressure, none
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What is the best response in each category?
Eyes - spontaneous eye opening
Verbal - orientated
Motor - obeys commands
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What is the 4 criteria when assessing eyes?
Spontaneous
To sound
To pressure
None
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If a patient's eyes are completely swollen, how would you record the eyes assessment?
NT - Not Testable
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What is the 5 criteria for assessing verbal response?
Orientated
Confused
Words
Sounds
None
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If a man is asked a series of questions in the verbal assessment, and gets everything right, except the month, what would you record?
Confused
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What is the 6 criteria for assessing motor function?
Obeys commands
Localising
Normal flexion
Abnormal flexion
Extension
None
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If a patient bends their elbow when pressure is applied to the nail bed, what should you do next?
Move on to the trapezius pinch
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If a patient moves their hand up above their collarbone when the trapezius pinch or supraorbital pressure is applied, what is recorded?
Localising
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What is a decorticate rigidity motor response?
Abnormal flexion
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What is a decerebrate rigidity motor response?
Extension
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What numbers are given to the criteria?
The best response is given the highest number
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Give an example of this for each category
Eyes - if patient spontaneously opens, you give them a 4
Verbal - if patient is orientated, you give them a 5
Motor - if a patient obeys commands, you give them a 6
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Interpret E3, V2, M6
Eyes responds to sound
Verbally responds with sounds only
Motor - obeys commands
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Interpret E4, V1, M2
Eyes open spontaneously
No verbal response
Motor extension
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Interpet E2, V3, M4
Eyes open in response to pressure/pain
Verbally responds with incoherent words
Normal flexion
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What is the best and worst overall GCS score?
15 is best, 3 is worst
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You suspect a patient has had a stroke. How would you assess them?
Face - can they smile? is there a visible droop?
Arm - can they lift both arms above head?
Speech - can they talk? is speech altered?
Time - time to call for help
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How do you assess pupillary response?
Shine a bright and focused light into each of the patient's eyes. In response, an intact nerve will cause pupillary constriction
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When assessing pupillary response, what should the nurse record?
Size, shape and symmetry of pupils, and the speed of reaction to light
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What is the normal pupil size?
Around 2.5mm
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When shining a light in the eyes, what nerve is affected?
The third cranial nerve (oculomotor)
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Which common drug groups might cause pinpoint pupils?
Narcotics and opioids
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What is miosis?
constriction of pupils
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What is mydriasis?
dilation of pupil
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Other cards in this set

Card 2

Front

What does AVPU stand for?

Back

Alert
Voice
Pain
Unresponsive

Card 3

Front

If concerned, how you can you further assess neurological condition?

Back

Preview of the front of card 3

Card 4

Front

What are the 3 components of the GCS?

Back

Preview of the front of card 4

Card 5

Front

What are the 4 steps when completing the GCS assessment?

Back

Preview of the front of card 5
View more cards

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