assessing the sensory- neurological system. outcomes 4 identify pertinent neuro/sensory history...
TRANSCRIPT
ASSESSING THE SENSORY-NEUROLOGICAL SYSTEM
Outcomes Identify pertinent neuro/sensory
history questions. Obtain a neuro/sensory history. Perform a neuro/sensory physical
assessment.
(Continued)
Outcomes Document pertinent neuro/
sensory assessment findings.
Identify actual/potential health problems stated as nursing diagnosis.
Differentiate between normal and abnormal findings.
Structures Cerebrum Cortex Frontal lobe Temporal lobe Limbic system Parietal lobe Occipital lobe RAS Thalamus Hypothalamus Cerebellum Brainstem Midbrain Medulla Meninges Ventricles
FunctionsWhat are the functions of…
Cerebrum: Largest part of brain
Cortex: Outer layer of cerebrum; controls
most conscious processesFrontal Lobe:
Emotional expression, Broca’s area (expressive language) (Continued)
FunctionsWhat are the functions of…
Temporal lobe:
Hearing, taste, smell, memory, Wernike’s (language comprehension)
Limbic system: Emotions, sexual arousal, behavioral
expression, recent memory (Continued)
FunctionsWhat are the functions of…
Parietal: Sensory input
Occipital lobe: Vision and spatial relationships
RAS: Wakefulness
(Continued)
FunctionsWhat are the functions of…
Thalamus: Clusters multiple sensory stimuli
Hypothalamus: Controls autonomic nervous system
and pituitary glandCerebellum:
Coordination, equilibrium(Continued)
FunctionsWhat are the functions of…
Brainstem: Involuntary survival behaviors;
includes midbrain, medulla and pons
Midbrain: Visual, auditory, pupils, and eye
movements(Continued)
FunctionsWhat are the functions of…
Medulla: Regulates heart, respiratory rates,
B/P, and protective reflexesPons:
Helps with respiratory function, facial sensation and movement
(Continued)
FunctionsWhat are the functions of…
Meninges: 3 layers (pia, arachnoid, dura);
protect brain and spinal cordVentricles:
4 cavities; capillaries produce and reabsorb CSF
(Continued)
Relationship to Other SystemsWhat is the relationship of the neurologic/
sensory system to other systems? Integumentary Respiratory HEENT Musculoskeletal Lymphatic Genitourinary Cardiovascular Endocrine Hematological Gastrointestinal
DevelopmentalVariationsWhat developmental variations of the
neurologic/sensory system might you seen with:
ChildrenPregnant clientsOlder adults
Cultural Variations
What cultural variations of the neurologic/sensory system might be seen with:
African Americans Irish Native Americans
HistoryWhat can the history tell you about the neurologic/sensory system?
Biographical data Current health status Past health history Family history Review of systems Psychosocial history
SymptomsWhat symptoms would signal a problem with the neurologic/sensory system? Headache Mental status change Dizziness, vertigo, syncope Numbness or loss of sensation Deficits of the 5 senses
Physical AssessmentApproach: inspection, palpation, and
auscultation Position: sittingTools: stethoscope, B/P cuff, penlight,
gloves, cotton, sharp object, coin, fragrance, sweet and sour substance, tongue blade, test tubes, reflex hammer, ophthalmoscope
General Survey and head-to-toe scan
Cerebral Function Behavior Level of consciousness: time, place,
person Glasgow Coma Scale Memory: immediate, recent, remote Mathematical ability Thought process Judgement General knowledge Communication
Sensory FunctionSuperficial sensations: Light touch Pain Temperature
Deep sensations: Vibratory sensations Kinesthetics
(Continued)
Sensory FunctionDiscriminatory sensations: Stereognosis Graphesthesia 2 point discrimination Point localization Extinction
Deep Tendon Reflexes Biceps Triceps Brachioradialis Patellar Achilles
Superficial Reflexes Plantar Abdominal Anal Cremasteric Bulbocavernosus
Protective Reflexes
Gag Cough Swallow Blink Corneal
Primitive Reflexes
Babinski Sucking Grasp Rooting Snout Glabellar
Meningeal Signs
Nuchal rigidity
Kernig’s Sign
Brudzinski’s Sign
Motor Function Finger-to-nose Heel-to-shin Rapid alternating movements Romberg Gait: heel-to-toe