Neurological System

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Neurological System Nursing 330 Governors State University Shirley Comer

Transcript of Neurological System

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Neurological System

Nursing 330

Governors State University

Shirley Comer

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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

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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

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Pix Cranial Nerves

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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

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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

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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

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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

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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

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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

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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

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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

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Sensory assessment pix

Sharp Vibration

Finger Placement

Touch

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Dermatomes/spine

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Positioning

•Decorticate – disruption of lower spinal neurological tracts

•Decerebrate - Injury to the brainstem

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Deep Tendon Reflexes

4+ =Very Brisk, hyperactive /c clonus 3+ = more brisk than average 2+ = average, normal 1+ = Diminished, Low normal 0 = no response

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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

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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

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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

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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

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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

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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

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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

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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

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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”

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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

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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

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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

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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

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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

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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

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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

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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

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Rationale

D is the correct answer. He is not alert and this represents a change in his status which requires notifying the PHCP.

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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

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Rationale

B is the right answer. Cranial nerve V (Trigeminal) controls the jaw muscles