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Chapter 22: Assessing the Neurological

•	 Speech	problems
                                          •	 Memory	deficits
Short-term	memory	can	be	assessed	by	asking	the	person	to	remember	
                                          three,	unrel...
Listening (Auscultation)
                       We	assess	the	nervous	system	through	auscultation	by	listening	to	the	
•	 Demonstrating	movements	that	are	smooth	and	coordinated
                                        •	 Able	to	smell	famili...
Chapter 22 Review Questions

Define the following terms:                              Answer the following multiple-choice...
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Chapter 22: Assessing the Neurological System


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Chapter 22: Assessing the Neurological System

  1. 1. Chapter 22: Assessing the Neurological System What You Will Learn • Using inspection, auscultation, and palpation to assess the neurological system Author: Key Terms Nancy M. Birtley, APRN, BC, Affect — The emotional reaction associated with an experience Adult Psychiatric/ Mental Health Clinical Nurse Hallucination — A false perception having no relation to reality and not Specialist, Psychiatric Care and accounted for by any exterior stimuli Wellness Specialists, St. Louis, MO Delusion — False belief brought about without appropriate external stimulation and inconsistent with the individual’s own knowledge and experience Illusion — A misinterpretation of sensory impressions Contracture — Permanent contraction of a muscle due to spasm or paralysis Cogwheel Rigidity — Muscles responding with cogwheel-like jerks to the use of force in bending the limb Because the nervous system is the control center of the body, impair- ment, injury, or illness affecting the nervous system has great impact on all of the other body systems. Likewise, concerns in other systems of the body can also affect the nervous system. Chronic illnesses, such as heart When assessing the nervous system, it is important to review the resi- disease, hypertension, diabetes, dent’s past history. Chronic illnesses can impact the function of the cancer, and COPD, can impact the nervous system as can infections, surgeries, and prior injuries. Be aware function of the nervous system. of medications that individually or in combination impact how the ner- vous system functions. Sedatives, narcotics, and psychiatric drugs are just a few classes of drugs affecting the nervous system. Over-the- counter drugs (e.g., antihistamines) can have as much of a negative im- pact on the nervous system as prescription drugs. The following symptoms warrant further assessment of the nervous system: • General behavior change • Mood change • Loss of consciousness • Anxiety or nervousness FENCE Student Manual • Seizures 110
  2. 2. • Speech problems • Memory deficits • Motor problems • Sensory problems The resident with a neurological problem may be unaware of the The following reviews a neurological examination using observation (in- condition or symptoms. Therefore, spection), listening (auscultation), and palpation as they relate to the ner- it is helpful to elicit information vous system. The first section covers the mental status examination, which from a significant other as to symp- provides important information about the resident’s overall functioning as toms and changes in behavior. well as one’s ability to adapt to one’s environment. Observation (Inspection): The Mental Status Examination Begin by observing the person’s level of consciousness? Is the resident alert and awake, or drowsy, lethargic, or unresponsive? Assess the person’s appearance and grooming. For example, is she dressed appropriately for the situation or weather/season? Are there layers of clothing or parts of clothing missing? Is there any body odor? Pay special attention to make- up, accessories, style of dress. Is she extravagantly dressed with excessive makeup and accessories? Note the person’s overall mood. For example, does he laugh or joke appro- priately for the situation? Is he on the verge of tears or crying? Is he angry or irritable? Ask questions which may elicit feelings. For example, “How do you feel about being here?” or “Tell me about your family.” Observe the person’s facial expression or affect. Is the affect congruent with the topic of discussion? For example, if the person is speaking of his wife’s death, you would expect the affect to be sad. Some individuals may have a blunted or flat affect which shows no emotion. Neurological disorders may result in an inability of the facial muscles to smile or frown, among other expressions. The term “mood” refers to what Watch the person walk. Note the posture and balance. Is the resident the person is feeling and is sub- leaning, shuffling, or dragging a foot? Are there any involuntary move- jective. The term “affect” refers ments, such as jerking, facial ticking, foot tapping, pelvic thrusting, rock- to what the observer sees and is ing, pill-rolling of the fingers, puffing of the cheeks, or tongue thrusting? objective. Describe any tremors or restlessness of the limbs. Does the speed of movement appear normal, slow, or fast? Assessing memory, intellect, insight, and judgment may also be included in observation. Memory can be difficult to assess as many residents are able to cover confusion in a superficial conversation. By asking questions specific to orientation to time, place, and person, the nurse can get a better idea of the person’s memory. Ask about the month, date, day, year, season, city, state, facility, or address. Engage the person in a conversation about current events that are well known and publicized, such as a presi- dential election or a current war. The nurse can add to memory assess- ment by asking for the names of the last three presidents. FENCE Student Manual 111
  3. 3. Short-term memory can be assessed by asking the person to remember three, unrelated objects five minutes after they were introduced. For example, tell the person you are going to ask them to remember three things: dog, key, and banana. Ask the person to repeat the items. When five minutes have passed, ask about the three items to remember. Short- term memory can also be assessed by asking the person what they ate at the last meal, provided the nurse is aware of what the resident actually ate. Long-term memory involves distant past. For example, does the person remember how many siblings he had or if his parents are still living? Assessing long-term memory may require the assistance of a significant other who can confirm or deny the answers. Intellect can be observed by listening to the person’s vocabulary and grammar. Asking about education and work experience may help to quantify intellect. For example, ask the person if she is familiar with her medical diagnoses and medications. Do her goals correlate with her physi- cal and mental capabilities? Can she count backwards from 100 by 7 at a time? Can she spell “world” forwards and backwards? Abstract think- ing is another component of intellect. Is the resident able to interpret the meaning of the proverbs, “A stitch in time saves nine,” or, “A rolling stone gathers no moss”? The proverb, “A stitch in time saves nine,” means that if a job needs to be done, it is best to do now because it will only get more difficult later. The proverb, “A rolling stone gathers no moss,” means that people who are always moving, with no roots in one place, tend to avoid responsibilities and cares. If the resident explains the proverbs literally, such as, “If you put in one stitch, you won’t need to do the rest of them,” this answer indicates difficulty with abstract thinking. In some settings, it may be helpful to ask the person’s significant other about the resident’s ability to plan a meal, balance a checkbook, and pay bills. Hallucinations may be visual, audi- Thought content is another component of the mental status examina- tory, olfactory, gustatory, or tactile. tion that can be observed. Note hallucinations, delusions and illusions. Some residents may experience paranoid delusions that people are talking about and against or trying to harm them. Grandiose delusions involve an inflated sense of self importance. A resident who is experiencing grandi- ose delusions may, for example, believe himself to be rich and influential. Somatic delusions may result in believing one has a terrible illness. An illusion is misinterpretation of a real stimulus. There is a difference be- tween an illusion and hallucination. Looking at a white wall and seeing roaches is hallucinating. Looking at a white wall with large black scuffs and seeing those scuffs as roaches indicates that the resident is experi- encing an illusion. Thought content may also involve obsessions, somatic complaints, excessive guilt, blame, hyper-sexuality, and hyper-religiosity. FENCE Student Manual 112
  4. 4. Listening (Auscultation) We assess the nervous system through auscultation by listening to the person’s voice quality and articulation. Some neurological disorders make it difficult to speak loudly enough for others to hear. In addition, the abil- ity to form words clearly can be compromised by a neurological disorder because the nerves that control tongue and mouth movement are affected. Is the speech mumbled, stuttered, or incoherent? Does the resident have difficulty coming up with the correct term? Listen to the resident’s flow of thought. For example, does he give exces- sive, unnecessary details (circumstantiality)? Does he digress from the topic (tangentiality)? Does his communication use complete sentences, or is it full of meaningless, unrelated words (word salad)? Does he express a series of thoughts that seem distantly or loosely related to one another (loose association)? Is his speech a nearly continuous flow, jumping from topic to topic (flight of ideas)? Palpation Muscle tone and strength are greatly affected by the nervous system. It is helpful to assess hand grips to determine if the grips are equal. Have the person squeeze the first and second fingers of the nurse’s hands. Are the hand grips equal? When the resident makes a muscle with the biceps, is the nurse able to force the arm to straighten without difficulty? Does the musculature appear symmetrical? Are the muscles in a particular joint contracted? A contracture is a permanent contraction of a muscle due to spasm or paralysis. In some situations, muscle rigidity may cause joint resistance. The nurse can check for this resistance, called cogwheeling, by holding the resident’s elbow in one hand and bending and straightening the arm with the other hand. If there is cogwheeling, the nurse will feel a jerking resis- tance while bending and straightening the arm. When muscles respond with cogwheel-like jerks to the use of force in bending the limb, it is called cogwheel rigidity. In addition to that listed above, further assessment of the neurological system may reveal specific weaknesses requiring nursing intervention. The main purpose of the neurological examination is to identify problems and develop a plan to help residents cope effectively with self care deficits during their activities of daily living. The nurse evaluates whether the per- son can see, eat, speak, feel, move, and eliminate. Is the resident: • Alert, oriented, and aware of the past and present? • Emotionally stable and able to understand verbal and written in- structions • Able to speak and write? FENCE Student Manual 113
  5. 5. • Demonstrating movements that are smooth and coordinated • Able to smell familiar scents • Hear sounds of various ranges and volume • Taste salt, sour and sweet • Feel sharp, soft, hot and cold • Able to maintain bowel and bladder function The human body is a wondrous result of delicate balance and interaction A deficit in the nervous system between organ systems. While the nervous system is the control center can change a person’s very exis- of our body, it affects and is affected by all other systems. It maintains tence and devastate his quality of memories, experiences, and emotions and makes each person a unique life. individual. FENCE Student Manual 114
  6. 6. Chapter 22 Review Questions Define the following terms: Answer the following multiple-choice questions: 1. Affect — 12. Which of the following is a part of the Mental Status Examination: 2. Cogwheel Rigidity — a. Heart rate b. Lung sounds 3. Contracture — c. Skin tone d. Thought content 4. Delusion — 13. Which of the following is a type of hallucination: 5. Hallucination — a. Paranoia 6. Illusion — b. Catatonia c. Tactile Circle “True” or “False” as appropriate for the d. Disorganized following statements: Complete the following: 7. (True/False) — Past history is insignificant when assessing the nervous system. 14. List four medications which can have a nega- tive impact on the nervous system: 8. (True/False) — Chronic illnesses, such as a. heart disease, hypertension, diabetes, cancer, and COPD, can impact the function of the b. nervous system. c. d. 9. (True/False) — The resident with a neuro- logical problem may be unaware of the condi- 15. What are two types of memory assessed in tion or symptoms. the Mental Status Examination? a. 10. (True/False) — The Mental Status Examina- b. tion gives an indication of how the resident is functioning as a whole and adapting to the 16. How might you assess the resident’s abstract environment. thinking? 11. (True/False) — A deficit in the nervous sys- tem can change a person’s very existence and devastate quality of life. 17. Describe how to assess for cogwheel rigidity. FENCE Student Manual 115