Resources
http://philschatz.com/anatomy-book/contents/m46577.html
https://lane.stanford.edu/portals/cvicu/HCP_Neuro_Tab_4/Neuro_Assessment.pdf
Pupillary Assessment:
Neurological/ Sensory Perception Assessment
Assessing the pupils:
- size
-shape
-reactivity of light
-comparison of one pupil to the other.
Level of Consciousness:
- Observe patient's:
~ normal voice
~ shout
~ light touch
~ pain
Use Glasgow Coma Scale (GSC) if
assessment of awareness progresses.
The cerebellum is responsible for muscle coordination and balance on the same side.
Testing:
- Finger to Finger test
- Finger to nose test
- Tandem Walking
- Romberg Test
Interview:
- Gather subjective and objective data
- Background information
- Clarify information
- Develop a relationship with client
-Look at the muscles on each side of the body.
-Reflex response:
0 no response
1+ diminished, low normal
2+ average, normal
3+ brisker than normal
4+ very brisk, hyperactive
Assessment Overview:
- Interview
- Level of Consciousness
- Pupillary Assessment
- Vital Signs
- Motor Function
-Sensory Function
- Tone
- Cerebellar Function
Definitions:
-Receptors are sensitive to the five senses.
- Perception is dependent on sensations, but not all sensations are perceived.
There are three main pathways for sensation and they should be compared bilaterally:
- pain and temp. sensation
- position sense
- light touch
- Observe:
~ muscle size
~ muscle tone
~ muscle strength
~ involuntary movements
~ posture, gait
- Sensory Perception: occurs in organisms capable of performing neurophysiological processing of the stimuli in their environment.
~ the five senses
- Perception: the central processing of sensory stimuli into a meaningful pattern
- Receptors: the cells or structures that detect sensations.
- Trransmembrane protein receptor: a protein in the cell membrane that mediates a physiological change in a neuron
- Ligands: chemicals that activate transmembrane protein receptors.
Focus should be on arm and leg movement
Respiratory:
- Ensure patient airway is maintained
- Assess rate, rhythm, and characteristics of inspiration/ expiration
- Assess gas exchange, tissue perfusion, airway clearance, and risk of aspiration
- Assess for causes of respiratory disturbances or secondary conditions that can cause respiratory complications
-Assess for actual respiratory complication/ insufficiency and intervene appropriately
- Blood Pressure, Temperature, Pulse