Weber Ch 10 & 11 Neuro

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cswett
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Weber Ch 10 & 11 Neuro
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2011-11-21 10:54:28
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Weber 10 11 Neuro
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Weber Ch 10 & 11 Neuro
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  1. Nervous System
    • Central Nervous System (CNS)
    • –Brain
    • –Spinal Cord

    • §Peripheral Nervous System (PNS)
    • –Cranial Nerves (12)
    • –Spinal Nerves (31)

    • §Autonomic Nervous System
    • –Sympathetic Nervous System
    • –Parasympathetic Nervous System
  2. Skull & CSF
    • §Skull
    • §Meninges (dura mater, arachnoid, & pia mater)

    • Dura mater = outer fibrous double layer
    • Arachnoid = middle elastic membrane covering brain
    • Pia = inner layer with blood supply to brain

    §Blood supply

    • §Cerebrospinal fluid
    • –Colorless, odorless fluid
    • –Choroid plexus; arachnoid villi
    • –Cushions, maintains intracranial pressure, nutrition, and
    • removes metabolic wastes
  3. 4 major divisions in brain
    Cerebrum – higher intellect; 4 lobes; contralateral = opposite side controls body

    Diencephalon – relay station & homeostasis

    Brain Stem – midbrain, pons & medulla oblongata with spinal cord

    Cerebellum – balance & coordination; ipsilateral = same side controls body

    Cerebrum, diencephalon, cerebellum, and brainstem

    Gray matter (brain cell bodies)/white matter (myelinated nerve fibers)
  4. CEREBRUM
    • §Frontal lobe =motor cortex
    • –Broca’s area, expressive aphasia

    §Parietal lobe =sensory cortex

    • §Temporal lobe =auditory cortex
    • –Wernicke’s area, receptive aphasia

    Occipital lobe =visual cortex
  5. DIENCEPHALON
    §Thalamus-relay station

    §Hypothalamus-homeostasis

    §Epithalamus-sleepiness - sleep/wake center

    • §Subthalamus-ANS
    • –Sympathetic
    • –Parasympathetic
  6. Brain Stem
    • §Midbrain
    • §Pons
    • §Medulla oblongata
    • –10 of 12 cranial nerves (“CN’s”)
    • –Contralateral/cross over
  7. Cerebellum
    §Coordinating movement, equilibrium, muscle tone, and proprioception


    Each hemisphere controls movement for same (ipsilateral) side of body
  8. Spinal Cord
    • Continuation of medulla oblongata to L1, L2
    • §Nerve fibers (tracts)
    • §Myelinated nerves (white matter)
    • –Descending (motor tracts)
    • –Ascending (sensory tracts)
    • §Gray matter (nerve cell bodies)
  9. Peripheral Nervous System
    • Cranial nerves (12 pairs)
    • –motor fibers (III, IV, VI, XI, XII)
    • –sensory fibers (I, II, VIII)
    • –mixed/both (V, VII, IX, X)
    • Some say marry money
    • but my brother says bad
    • business marry money
  10. Cranial Nerves (“On old Olympic’s towering top, a Fin and
    German viewed some hops”)
    • I - Olfactory (smell info from nasal cavity)
    • II - Optic (sight from retina; visual acuity & fields)
    • III - Oculomotor (extraocular eye movement, eyelids)
    • IV - Trochlear ( downward & inward eye movement)
    • V- Trigeminal (Sensory of cornea, eyelids, forehead
    • Motor: jaw opening & chewing)
    • VI - Abducens (Lateral eye movement)
    • VII - Facial (facial expression, rounded vowel sounds, taste-anterior 2/3)
    • VIII - Acoustic (hearing & equilibrium)
    • IX - Glossopharyngeal (swallowing, phonation, gag & taste-posterior 1/3)
    • X - Vagus (heart, lungs, digestion, larynx, pharynx)
    • XI – Spinal Accessory -( turn head, shrug shoulders)
    • XII - Hypoglossal (tongue for speech & swallow)
  11. Peripheral Nervous System
    • Spinal Nerves
    • –31 pairs—emerge from segments of spinal cord
    • 8 cervical
    • 12 thoracic
    • 5 lumbar
    • 5 sacral
    • 1 coccygeal nerves
  12. Superficial & Deep Tendon Reflexes (Reflex Arc)
    • Superficial Reflexes -
    • –Abdominal (upper T7-9, lower T10-11)
    • –Cremasteric (T12, L1-2)
    • –Plantar / Babinski (L4-5, S1-2)
    • Deep Tendon Reflexes -
    • –Biceps (C5-6)
    • –Brachioradialis (C5-6)
    • –Triceps (C6-8)
    • –Patellar (L2-4)
    • - Achilles (S1-2)
  13. Neuro. Problem-Based History
    (“OLDCARTS”)
    • §Headache
    • §Dizziness/Vertigo/ Syncope
    • §Seizures
    • §Loss of Consciousness
    • §Memory Loss
    • §Tremors
    • Changes in Movement/ Mobility
    • Changes in Sensation (numbness & tingling)
    • Dysphagia (swallowing problems)
    • Aphasia/Dysphasia (communication problems)
  14. Neuro Health History: Past Medical History
    • §Injury to head/spinal cord? Describe. Changes since injury?
    • §Surgery on brain, spinal cord, or nerves? When? Outcome?
    • §Stroke? Describe. When? Changes resulting from stroke?

    • §Seizure disorder? Describe kind and how often. What prevents seizures?
    • §Meningitis or encephalitis?
    • §Chronic diseases?
  15. Family History
    • Family History
    • §Stroke?
    • §Seizures?
    • §Hypertension
    • §Tumors of brain or spinal cord?
    • Alzheimer’s disease
    • All these conditions have familial tendencies, and may affect vision. If there is a positive answer to any of these conditions, the client’s risk of developing them increases
  16. Lifestyle & Health Practices
    • §Noticed changes in ability to move around/participate in
    • usual activities (ADL)?
    • §Use of tobacco.
    • §Chemical or occupational exposure, such as lead, insecticides or pollutants?
    • §Diet deficient in niacin, folic acid or B12?
    • §Medications, taking as prescribed?
    • §Alcohol use per week?
    • §Use/ever used marijuana, cocaine, barbiturates, tranquilizers, or other mood-altering drugs?
  17. Health History: Risk Factors
    • §“Brain attack”, Cerebrovascular Accident (CVA)
    • - used interchangable - faster you get intervention the better off they will be
    • –Age: older at greater risk

    • –Gender: men at greater risk than women (women – more than half of deaths from brain attacks)
    • –Family history: risk greater if parent, grandparent, or sibling had a CVA
    • –Previous brain or heart attack
    • –Race (Blacks > whites) higher incidence of hypertension
    • –Smoking
    • –High blood pressure (HT)
    • –Diabetes mellitus (DM)
    • –Coronary artery disease (CAD)
    • –Transient ischemic attack (TIA)
    • –Atrial fibrillation
    • –High serum cholesterol
    • –Obesity
    • –Excessive alcohol intake
    • –Cocaine use
  18. Neuro. Physical Exam:
    • §Mental status / level of consciousness
    • §Cranial nerve exam
    • §Motor and cerebellar exam
    • §Sensory exam
    • §Reflexes (deep tendon & superficial)
  19. Assess Mental Status
    • §General Observation of:
    • –Posture & body movements - should be erect with relaxed body tense indicates anxiety while slumped &
    • slow with depression & bizarre = schizophrenia
    • –Dress, grooming & hygiene (appropriate) -for weather
    • outlandish = manic
    • soiled = depression
    • –Facial expressions esp. eye contact - Parkinson
    • & Alzheimer’s with mask-like expressionless face
    • –Mood/affect - positive attitude
    • –Concentration/focus
    • –Orientation x 3
  20. Assessment of Cognition
    • •Recent memory - what ate past 24 hrs. or weather today
    • •Remote memory
    • •Memory of learned information - 3 unrelated words then repeat after 5 min., 10 min. & 30 min.
    • •Abstract reasoning - proverb like rolling stone gathers no moss or how are orange & apple similar?
    • •Judgment - driving & police car behind with lights & siren on (what do you do?)
    • •Visual perception/construction
  21. Assess Orientation x 3
    • §Awareness - determine if oriented to:
    • §Date/time—first orientation to disappear
    • §Place—2nd orientation to disappear
    • §Person—last orientation to disappear
    • –Orientation returns in opposite order
    • §Arousal- determine Glasgow Coma Scale
    • –Assess for best response to eye opening, motor response, and verbal response
    • -Pain—1 descriptor used in assessment of best eye/motor response
  22. Assess Unconscious Patient
    • Glasgow Coma Scale ( 3 to 15)
    • Glasgow score 15 = optimal
    • < 10 = emergency
    • < 7 = coma

    • Best eye-opening response
    • §Spontaneously [4]
    • §To verbal command [3]
    • §To pain [2]
    • §No response [1]
    • §Peripheral v. Central Pain

    • Best verbal response
    • §Oriented, converses [5]
    • §Disoriented, converses [4]
    • §Inappropriate words [3]
    • §Incomprehensible sounds [2]
    • §No response [1]

    • Best motor response
    • –Obeys command [6]
    • – Localization of pain—moves to try and remove stimulus [5]
    • –Attempt to withdraw from stimulus [4]
    • –Abnormal flexion (decorticate) [3]
    • –Abnormal extension (decerebrate) [2]
    • –No response [1]
  23. Decorticate Posturing
    • caused by lesion at or above the brain stem
    • §Rigidly still
    • §Arms flexed
    • §Fists clenched
    • §Legs extended
  24. Decerebrate Posturing
    • caused by lesion below brain stem - intracranial catastrophie
    • §Rigid body position
    • §Arms stiff, extended & pronated inward but fingers are extended out
  25. Examination Cranial Nerves
    • §Evaluate speech—articulation, voice quality,
    • conversation/health history (CN II – XII)

    • §Test nose—smell (CN I)
    • §Test eyes—visual acuity (CN II), peripheral vision
    • §Observe eyes for extraocular movement (CNs III, IV, VI) in 6 cardinal fields
  26. Examination Cranial Nerves
    • §Observe eyes—pupillary size, shape, equality, constriction, accommodation
    • –PERRLA (CN III)
    • –Ptosis (droopy eyelid)

    • §Evaluate face—movement/sensation (CNs V/VII)
    • –Motion (clench teeth & palpate masseter muscle)
    • –Light touch over scalp, paranasal sinus & jaw
    • –Deep sensation (blunt vs. sharp paperclip)
    • –Corneal reflex
    • Raise eyebrows, smile, puff cheeks, purse lips, show teeth, & close eyes with resistance

    • §Test ears—hearing/balance (CN VIII)
    • –Whisper test, Weber/Rinne (tuning fork)

    • §Test tongue—taste (CNs VII,IX)
    • –Sweet, salty (VII); sour, bitter (IX)
    • –Not done unless reported problem

    • §Inspect oropharynx—gag reflex/soft palate movement (CNs IX, X)
    • –“aahhhh” test
    • Touch posterior pharynx with tongue blade for
    • gag
  27. Examination Cranial Nerves
    • §Inspect tongue—movement, symmetry, strength, absence of tumors (CN XII)
    • –protrude tongue, move toward nose, chin, side
    • to side
    • –press tongue against gloved finger

    §Test shoulder/neck muscles—strength/movement (CN XI) shrug shoulders; turn head to side against hands/resistance
  28. Examination: Cerebellar : Balance & Coordination
    "Drunk test"
    • §Observe walking/gait
    • §Romberg test - stant with feet together
    • §Upper extremities-
    • –Alternate thigh taps
    • –Finger to nose
    • –Fingers to thumb

    • §Lower extremities-
    • –Heel- to-toe walk
    • –Hop on one foot
    • –Stand on one foot x 5 sec
    • –Heel –to-shin- in bed - take opposite heel and slide down shin
    • –Deep knee bends
    • –Walk on toes then on heels
    • –Slide heel from knee to shin

    • §Evaluate Muscle Strength
    • –Client flexes muscles then resists when examiner applies opposing force (push/pull)
    • Fasciculation = localized uncontrollable twitch
  29. Examination - Sensory Function
    • §Eyes closed examine up extremities & check
    • dermatome map
    • - Tuning fork/cotton swab/paper clip - sharp & dull

    §Kinesthetic position - atoms in motion - eyes closed and move finger or toe up or down - pt itdentifies

    • §Stereognosis
    • - familiar object in hand - key or quarter

    • §Graphesthesia
    • - draw a litter

    • §2-point Discrimination
    • - tell if touching in two places or one
  30. Exam: Deep Tendon Reflexes
    • Evaluate DTRs muscle contraction, 4+ scoring system:
    • 0 = no response
    • 1+ = sluggish/diminished
    • 2+ = active or expected
    • 3+ = slight hyperactive, more brisk than normal
    • 4+ hyperactive with intermittent clonus


    • Triceps (C6, 7 & 8) contraction of triceps muscle; extension of elbow
    • Biceps (C5-6)—contraction of biceps muscle; flexion of elbow
    • Brachioradialis (C5-6) —pronation of forearm; flexion
    • of elbow
    • Patellar (L2, 3 & 4) —contraction of quadriceps muscles; extension of lower leg
    • Achilles (S1 & 2)—contraction of gastrocnemius muscle; plantar flexion of toes
    • Plantar/ Babinski (L4 & 5 S1 & 2)—plantar flexion of
    • toes yet superficial reflex
    • Ankle clonus—if hyperactive reflexes—sharply dorsiflex foot, maintain no movement
  31. Superficial Reflexes
    • §Upper & Lower Abdominals – stroke outward from umbilicus
    • §Cremasteric – stroke upper inner male thigh & ipsilateral testicle rises
    • §Plantar/Babinski’s – sole of foot upward; normally (-) flex toes; abnormal (+) if big toe dorsiflex & others fan
    • outward
  32. Elderly Neuro Variations
    • Effects of aging on nervous system :
    • §Dilation of brain ventricles
    • §Cortical atrophy esp. frontal/temporal lobes
    • §Decreased brain weight
    • §Decreased norepinephrine & serotonin causes depression while decreased dopamine leads to Parkinson’s disease
    • §Eye lens thickens; smaller pupil—brighter light for vision
    • §50% of those >75 years report hearing difficulties
    • §Short-term memory declines with age, long­term memory usually maintained
    • –Changes in motor function—stooped, forward-flexed posture, slow gait
    • –Change in gait—related to age-associated conditions (osteoarthritis/osteoporosis)
    • –Loss of muscle strength and slow reaction esp. plantar & abdominal reflexes
    • Visual deficits, loss of muscle strength, and slowed reaction time contribute to increased risk
    • of falls
    • Presbyopia = problems with near
    • vision (farsighted) as age
  33. Nursing Dx Neuro
    • §Risk for injury RT decreased sensation
    • §Risk for aspiration RT impaired gag reflex
    • §Impaired verbal communication RT aphasia
    • §Acute or chronic confusion RT head injury
    • §Impaired memory RT dementia
    • §Self-care deficit RT paralysis
    • §Incontinence RT spinal cord injury
    • §Unilateral neglect syndrome RT CVA
    • §Disturbed thought process RT drugs or ETOH (Risk of suicide)
    • §Anxiety/Fear
    • Low self-esteem
  34. Deep tendon reflexes
    • §Biceps (inner elbow palm up)
    • §Brachioradialis (wrist palm down)
    • §Triceps (hand arm down)
    • §Patellar (below knee)
    • §Achilles (behind ankle)
    • §Check for Ankle clonus if 4+ (dorsiflex foot – no movement is normal v. oscillations = clonus)

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