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Neurological System

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  • 1. Neurological System Nursing 330 Governors State University Shirley Comer
  • 2. Relevant History
    • Headaches (location, frequency, duration
    • weakness or incoordination
    • Head injury numbness or tingling (parasthesia)
    • Dizziness Difficulty swallowing
            • (dysphagia)
    • Seizure Difficulty speaking
    • Syncope (fainting) (dysphasia)
    • Tremors Past history of neuro
  • 3. Cranial Nerves
    • 1. Olfactory- smell 2. Optic – vision
    • 3. Oculomotor – sight 4. Trochlear – vision
    • 5. Trigeminal – mouth and jaw
    • 6. Abducens - Vision
    • 7. Facial – facial muscles
    • 8. Acoustic – hearing
    • 9. Glossopharyngeal- speech and soft palate
    • 10. Vagus – palate 11. Spinal – shoulders
    • 12. Hypoglossal - tongue
  • 4. Pix Cranial Nerves
  • 5. Testing Cranial Nerves
    • I - Olfactory- test when pt reports decreased sense of smell
      • Place aromatic substance under each nostril
      • Should be able to identify bilaterally
    • II – Optic
      • Test visual fields
      • Use ophthalmoscope to examine retina and observe optic disk
  • 6. Testing Cont
    • III, IV, and VI – Oculomotor, Trochlear and Abducens
      • Observe pupil size and reactivity (PERRLA)
      • Assess extraocular movements and cardinal positions of gaze
        • Nystagmus oscillation of eye abnormal
        • Ptosis – drooping eye lids
  • 7. Testing Cont
    • V – Trigeminal
      • Palpate muscles as pt clenches teeth
      • Test sensory function by touching cotton wisp to face /c eyes closed. Pt says “now” when felt
      • Corneal Reflex for those /c abnormal facial movements
        • Touch cotton to cornea – should blink bilaterally
    • VII – Facial
      • Observe for facial symmetry
        • Smile, frown
        • Close eyes
        • Lift eyebrows
        • Puff cheeks
  • 8. Testing Cont
    • VIII – Acoustic – test hearing acuity with whispered voice, Rinne and Weber tests
    • IX and X – Glossopharyngeal and Vagus
      • Watch uvula as pt says “Ahhh”- use tongue blade
      • Test gag reflex when appropriate – use blade
    • XI – Spinal Accessory
      • Shrug shoulders and turn head against your resistance
    • XII – Hypoglossal – stick out tongue
      • No tremors or deviations from midline
  • 9. Cerebellar Function
    • Gait – normal gait smooth with arms swinging opposite. Step is 15 inches
      • Walk 10 to 20 feet- Ataxia= uncoordinated or unsteady gait
      • Walk heel to toe – will accentuate any problems
    • Balance
      • Romberg test- stand /c hands at side and feet together /c eyes closed
        • Should hold position (protect pt from fall)
      • Hop in place – demonstrates normal strength and cerebellar function
  • 10. Coordination and Skilled Movements
    • Rapid Alternating Movements
      • Pat knee alternating palm /c back of hand and increase speed
    • Finger to finger test
      • Touch your finger and then touch his nose- change finger position several times
    • Finger to nose test
      • /c eyes closed have pt touch his own nose /c out stretched arms
    • Heel to shin test
      • While supine have pt touch heel to opposite shin and slide heel down leg
  • 11. Sensory System
    • Test sensory function of extremities and trunk
    • Perform on those exhibiting deficits
    • Pain
      • Use pin prick- ask pt if dull or sharp
      • Do bilaterally and compare
    • Temperature - do only when pain is abnormal
      • Test tubes of hot v. cold water
    • Light touch - Use cotton wisp
  • 12. Sensory Cont
    • Vibration -use low tuning fork-place on bony area
    • Position- passively move extremity and ask pt what position
    • Stereognosis – ability to recognize objects tactically
    • Graphesthesia – ability to read a number traced on the skin
    • 2 point discrimination - use 2 or more sharp points and ask pt how many they feel
  • 13. Sensory assessment pix Sharp Vibration Finger Placement Touch
  • 14. Dermatomes/spine
  • 15. Positioning
    • Decorticate – disruption of lower spinal neurological tracts
    • Decerebrate - Injury to the brainstem
  • 16. Deep Tendon Reflexes
    • 4+ =Very Brisk, hyperactive /c clonus
    • 3+ = more brisk than average
    • 2+ = average, normal
    • 1+ = Diminished, Low normal
    • 0 = no response
  • 17. Deep Tendon Reflexes cont
    • Hyperreflexia
      • an exaggerated reflex
      • occurs /c upper motor neuron lesions
    • Hyporeflexia
      • absense of reflex
      • occurs /c lower motor neuron lesion
    • Clonus – set of short jerky contractions of the muscle
  • 18. Deep Tendon Reflexes cont
    • Biceps- above antecubital area on inner arm
      • place thumb on biceps tendon
    • Triceps – above elbow
      • lift arm at elbow
    • Brachioradialis- above thumb on arm
      • lift thumb
    • Quadriceps – below knee
      • Let leg dangle
    • Achilles – behind heel
      • Dorsal flex foot
  • 19.  
  • 20.  
  • 21. Superficial Reflexes
    • Abdominal reflex – stroke abdomen from flank toward umbilicus
    • Cremasteric Reflex – stroke inner thigh of male should result in elevation of testicle
    • Babinski Reflex – stroke lateral side of sole of foot in upside down “J” pattern
      • In adult- toes curl
      • In infants- toes fan
  • 22. Mental Status
    • A person’s emotional and cognitive functioning.
    • Mental Status is subjective and Inferred from
        • Consciousness
        • Language
        • Mood and affect
        • Orientation
        • Attention
        • Memory
        • Abstract reasoning
        • Thought process
        • Thought content
        • perceptions
  • 23. Factors Effecting Mental Status Evaluation
    • Illness or health problems
    • Current medications and their side effects
    • Educational background
    • Usual behavior
    • Stress level
    • Sleep habits
    • Drug and alcohol use
  • 24. Levels of Consciousness
    • Alert- awake and easily arousable- oriented x3
    • Lethargic (somnolent)-Difficult to arouse, drowsy, thinking slow but appropriate
    • Obtunded - Sleeps most of the time, confused when aroused, speech mumbled
    • Stupor ( semi comatose)- responds only to vigorous shake or pain non verbal except for moans ect
    • Unresponsive - completely unconscious, no response to pain
    • Delirium - awake but extremely confused esp @ noc, may be violent, incoherent speech
  • 25. Assessing Level of Consciousness
    • 1 st call name, if no response call louder
    • 2 nd call name and lightly touch person
    • 3 rd call name and shake shoulder of person, if no response shake harder
    • 4 th Apply pain
      • Sternal rub
      • Pressure on eyebrow ridge
      • Pinch sternal or chest area
      • Don’t pinch or twist nipples
      • May try shining light in eye
  • 26. Assess Cognitive Function
    • Orientation
      • Time, Place and Person = oriented x 3
    • Attention span
    • Recent memory- often impaired in Alzheimer’s
    • Remote memory- often intact even when acutely confused
    • Judgment- assists in planning safety needs
  • 27. Assess Thought Process and Perceptions
    • Thought Processes - are thoughts logical and orderly
    • Thought content - is the subject appropriate and logical
    • Perceptions- How does world treat him- paranoid?
    • Screen for suicidal thoughts - If depressed ask about thoughts “have you felt like hurting yourself”
  • 28. Age Specific Consideration
    • Infants and children
      • may be difficult to assess r/t lack of verbal skills
      • Must use keen observation
    • Teens appearance is often bizarre
    • Elderly may be forgetful or slow to answer
      • give them adequate time to respond
  • 29. Age Specific Considerations
    • Infants
      • Cannot directly assess cranial nerves, must observe infant behavior
        • II,III,IV,VI – assess pupil response, regards face of others, blinks eyes in response to light
        • V- Rooting and sucking reflexes
        • VII – Facial movements, smiling, wrinkling forehead, symmetrical
        • VIII- Moro Reflex /c loud noise to 4 months
        • IX, X – Swallowing, gag reflex
        • XII- Pinch infant’s nose results in mouth opening /c tongue midline
  • 30. Age Specific Considerations cont
    • Infants (cont)
    • Observe for symmetrical movements
    • Denver Developmental assessment
    • Infants prefer a flexed position
    • Head lag, limp, floppy trunk are abnormal
    • Spasticity is a sign of Cerebral Palsy
  • 31. Age Specific Considerations cont
    • Infant Reflexes
      • Rooting reflex – will turn head to side when cheek is touched – lasts till 3-4 months
      • Sucking Reflex-will suck anything in mouth- lasts until 1 yr
      • Palmer Grasp- will grasp anything in hand – lasts until 3-4 months
      • Planter grasp – toes curl – lasts till 8-10 months
  • 32. Infant reflexes Cont
    • Babinski- toes fan until 24 months
    • Moro – startle reflex – throws out limbs and then pulls in - lasts 1 to 4 months
    • Stepping Reflex – will place feet as if walking until 1 yo
  • 33. Age Specific Considerations cont
    • Children
      • Use Denver II to screen for developmental delays
      • Toddlers have broad gait
      • DTR are hard to assess as child cannot cooperate
      • Observe child’s voluntary movements
      • Make sure child cognitively understands test directions before recording a deficit
  • 34. Age Specific Considerations cont
      • Elderly
      • Responses may be slower
      • Taste and smell may decrease
      • Senile Tremors may occur, hands, head, tongue
      • Slow and deliberate gait r/t decreased spacial sense
      • /p 65 Achilles reflex often absent
      • DTR less brisk
      • Abdominal reflex may be lost if obese or skin has been stretched in pregnancy
  • 35. Practice Exam Question 1
    • In report, the previous nurse told you that Mr. Jones was alert and oriented x 3. While assessing Mr. Jones, you find him to be slow to respond but mostly appropriate. His speech is slurred and he often falls asleep during your assessment. How would you describe Mr. Jones, mental status?
    • A. He is alert and oriented just somewhat slow
    • B. He is obtunded
    • C. He is alert but not oriented
    • D. He is Oriented but not alert
  • 36. Rationale
    • D is the correct answer. He is not alert and this represents a change in his status which requires notifying the PHCP.
  • 37. Practice exam Question 2
    • Mrs. James has fallen and has a subdural hematoma. She is having trouble keeping her mouth closed and is drooling. What can you do to assess the appropriate cranial nerve?
    • A. Have her blink rapidly
    • B. have her clench her jaw and assess the muscle strength
    • C. Use a cotton wisp and gently touch her cornea
    • D. use a cotton wisp and gently touch her face
  • 38. Rationale
    • B is the right answer. Cranial nerve V (Trigeminal) controls the jaw muscles