neurological system
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Neurological System
Nursing 330
Governors State University
Shirley Comer
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
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
Pix Cranial Nerves
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
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
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
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
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
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
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
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
Sensory assessment pix
Sharp Vibration
Finger Placement
Touch
Dermatomes/spine
Positioning
•Decorticate – disruption of lower spinal neurological tracts
•Decerebrate - Injury to the brainstem
Deep Tendon Reflexes
4+ =Very Brisk, hyperactive /c clonus 3+ = more brisk than average 2+ = average, normal 1+ = Diminished, Low normal 0 = no response
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
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
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
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
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
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
Assessing Level of Consciousness
1st call name, if no response call louder 2nd call name and lightly touch person 3rd call name and shake shoulder of person, if no
response shake harder 4th 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
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
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”
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
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
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
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
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
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
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
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
Rationale
D is the correct answer. He is not alert and this represents a change in his status which requires notifying the PHCP.
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
Rationale
B is the right answer. Cranial nerve V (Trigeminal) controls the jaw muscles
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