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Nervous System
CNS Central Nervous System- Brain and the spinal cord
PNS Peripheral Nervous System- cranial nerves, spinal nerves, autonomic nervous system (ANS)
Brain: Cerebrum- ability to think/reason there are four lobes and to hemispheres (right and left hemisphere)
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Four lobes:
- - Parietal lobes: interpret pain
- - Occipital lobe: visual
- - Temporal lobe: teaching, comprehension
- - Frontal lobe: ability to reason and to know how to act. Good judgement personality
- Weinicke area: written and spoken word
- Broca area- being able to speak and write(aphasia)
- Basal Ganglia- automatic movement
- Thalmus- motor/sensory stimuli
- Hypothalamus- vital signs regulates your body temp, bp, piturary gland
- Limbic system- survival behavior
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Cerebellum
- Major motor and sensory pathway, coordinates voluntary
- movements, equilibrium
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Brainstem (medulla/pons)
- Regulates heart rate, breathing and swallowing, coughing.
- Sensory/motor pathways to and from the cerebral cortex
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Spinal cord:
- Primary pathway for messages to travel back and forth from
- the brain to the peripheral parts of the body. Sensory and motor pathways.
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PNS- cranial, spinal, ANS
- - Spinal- sensory and motor
- - Cranial- comes directly from brain 12 pairs
- - ANS- involuntary function of cardiac and smooth muscle glands. Sympathetic/parasympathetic
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Health Hx
- 1.PP- changes in mental statues, headaches,
- difficulty in speaking, walking, tingling and numbness. Drooping eyelids
2. Hx of and head injuries, surgeries, siezures, did you lose consciousness? For how long
3. FHx- of any strokes, siezures, htn
- 4. Anyone at risk- dm circulation, high
- cholesterol- risk for stroke
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PE of Neurological system
- - mental statuses and speech
- - cranial nerves
- - sensory
- - motor
- - reflexes
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Mental Status and Speech
LOC Level of Consciousness
- when you walk in the room does the pt respond to u saying his/her name. a change in this is an early indicator that something is
- going on with the pt;s neurological status.
Levels of Consciousness words to describe
- - Alert/wakefulness- responds to environment without delay
- - Confusion- disoriented (not sure who they are where they are), short attention span and not able to follow commands.
- - Drowisiness (lethargy)- responds with a lag
- before they answer
- - Stupor- unresponsive and you have to be physical in order to get their attention
- - Coma- unresponsive no matter what
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Mental status: LOC
Assessing Arousal/wakefulness
- Assessing Arousal/wakefulness
- Spontaneuous- walk in room and pt responds
- Normal voice
- Loud voice- yelling
- Tactile- touch
- Noxious – pain pinching nail bed
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MS/LOC
Glasgow coma scale
- - Standard assessment tool for assessing levels of consciousness
- - Eye response, verbal and motor response
- - Each parameter is given a score
- - A score of less than 7 means u are in a coma
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MS/LOC
Orientation
- Orientation to person, place, time- not knowing
- exact date is not important but knowing the season is good. Older patients need
- time to think about their responses. They maybe confused.
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MS/LOC
appearance and behavior
- Appearance and behavior- are they dressed
- appropriately for the season- hygiene intact
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MS/LOC
communication
Communication- clear and articulate
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MS/LOC
cognitive function
- - Memory (recent/long term)- short term memory goes first
- - Attention span- can pt follow conversation
- - Ability calculate- can pt count by 2’s
- - Thought content- what pt is saying is logical and it makes sense able to follow
- - Abstract reasoning- pysch and children pt are more concrete thinkers- but are they able to understand concepts like the early
- bird catches the worm.
- - Judgement/insight- able to evaluate situations and make good judgments.
- - Emotional status- facial expressions match the situations
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MS/LOC
pupillary response
- Pupillary response- PERRLA size shape reactive
- to light. Consensual
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MS/LOC
abnormal movements
- Abnormal movements- abn. Reflex posturing,
- involuntary movements
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Cranial Nerve Assessment
- 12 cranial nerves come from the brain
- known to be apart of the PNS
- Patient would need to be alert in order to do this
- assessment
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Cranial Nerve 1
- Olfactory- sense- smell- to test smell have pt close eyes
- and check each nostril with a different smell that people could recognize
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CN II
Optic Nerve- Sense- to see
- Visual acuity (snellen chart 20ft in distance..have patient
- for this eye test with each eye). Peripheral vision- confortation. If not able
- to use snellen have the person read something and document how they read and if
- that had any devices aiding them.
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CN III
- Oculomotor- motor
- Controls most eye movement, pupil response and eyelid
- function- test: having patient move eyes and eyelids. Use the pen light by
- using the consensual test
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CN IV
- Trochlear- motor
- Control eye movements downward and inward
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CN V
Trigmental- sense/motor
- Touch forhead, cheek, and jaw with cotton ball and have pt
- close eyes and ask where they feel u touching (sense). Jaw movement Chewing..have pt clench teeth to
- check muscle strength (motor). Ophthalmic (corneal reflex), maxillary,
- mandibular.
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CN VI
Abducens- motor
Controls lateral (side) movements of eye. H test to perform for all three nerves 3,4,6
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CN VII
Facial- sense/motor
- Facial expressions- muscles of face (motor). Taste on the
- anterior of the tongue 2/3 salt/sweet. (sense) abnormal would be drooping of
- the face
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CN VIII
Acoustics- sense
- Controls hearing- whisper test, Weber test (head) and Rinne
- test ac>bc (turning fork)
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CN IX
Glosspharyngeal- sense/motor
- Controls pharyngeal and swallowing (motor). Taste on the
- posterior of the tongue (sense)
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CN X
Vagus- sense/motor
Controls swallowing and speaking (motor)
- Controls sensations from the pharynx and carotids (palpate
- the carotids) (sense)
- Note if there is hoarseness in someone’s voice and if the
- person is unable to speak. If the person has uncontrolled drooling.
U can have person say, D N L T controls tongue movement
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CN XI
Accessory- motor
Head and neck movements
- Test with the shoulder shrug against resistance (testing
- strength). Also test by placing your hands on the person face and have them
- push against your hand…pushing against resistance. 0-5 below 3 is a disability
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CN XII
Hypoglossal- motor
- Involves tongue movement. Stick out tongue and move from
- side to side
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Assessment of Sensory Function
- - Screening
- - Testing the intactness of the peripheral nerve fibers, sensory tracts, and upper cortical discrimination
- - Pt need to be alert and oriented
- - Compares sensation on parts of the body
- - Try not to have a pattern
- - If u find a spot with alternative location find the border
- -Make sure to perform test with eye closed
DO THIS WITH THE PATIENTS EYE CLOSED
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Sensory assessment
- DO THIS WITH THE PATIENTS EYE CLOSED
- 1. light touch- with cotton in random places
- 2. pain sensation- something a little sharp
- 3. temperature- something warm or cold
- 4. position and motion sense movement of
- extremities- put your fingers on the persons big toe. Ask where are u touching
- and move around big toe and ask pt what u are doing.
- 5. Stereognosis- placing a coin (a familiar object)
- in the patient’s hand and asking them to identify
- 6. Graphesthesia- drawing a number in someone’s hand and asking them to identify like the number three.
- 7. Vibration sense- placing the turning fork on a bony prominence and asking patient if they feel it.
- 8. Point localization- able to sense and locate
- area that is being stimulated- touch area and ask where did I touch you.
- 9. Sensory Extinction- simultaneously touching both sides at the same point.
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Motor Function
- 1. Gait, posture and balance
- - heel to toe (tandem) walking)
- - Romberg test- stand with feet together and eyes close (checking for balance)
- 2. Muscle mass (size
- bulk)- atrophy/hypertrophy
- 3. muscle tone
- (resistance to muscles to strenching)
- 4. Muscle strength (0-5)
- - pronator drift- standing with your hands out and eyes close…checking arms balance
- - hand grip
- - pushing against resistance
- (testing for
- symmetry)
- 5. Coordination
- - rapid alternatate movements with your hands (hand flapping
- back and forth)
- - point to point testing finger to
- finger test, heel to shin test
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Deep Tendon Reflexes
- - Evaluates the intactness of spinal cords and
- motor/sensory function
- - Pt must be relaxed in proper postion
- - Tendon is struck briskly
- - Reflexes are graded from 0-4 (2+ is normal)
- - Testing biceps reflex- put thumb on tendon and strucking it with the narrow part of the hammer
- - Testing triceps tendon- using narrow part struck the dented place near the elbow
- - Brachioradialis tendon- struck neat the radial pulse with the big part of the hammer- hand should move
- - Patellar reflex- big part- hyperactive thyroid might have a big kic
- - Achullies reflex- whole body moves
- - If unable to perform document as unable to elicit.
- - Abdominal reflex- side to center with q-tip.
- Abd. Should move.
- - Plantar response- Babinski reflex- test
- underneath foot- toes should remain erect or curl under. It if fans out that
- indicates neurological problem. Only infants fan out.
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Nursing Dx.
- - Risk for ineffective cerebral tissue perfusion
- - Risk for injury- assisting to ambulate
- - Risk for aspirating – asssit with feeding
- - Impaired communication
- - Impaired physical mobility
- - confusion (acute/chronic)- administrated meds to help with confusion
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Caring for pt’s with a Hx of siezures
- - Neuro assessments
- - Maintain safe environment- bed low, side rails padded, three rails up, airway, suction equipment at bedside
- - Administred anticonvulsants as ordered. Evaluate other meds the could increase seizure activity
- - If seizures occur then accurate documentation
- Pre seizure- Aura, during- icital, post- post ictial
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Caring for a pt during a seizure-
- - maintain safety- clear the path of anything that could hurt the pt
- - assess airway needs, seizure activity
- - notify md
- - administer anticonvulsants as ordered
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- post seizure- VS including O2 stat, assess risk
- of injury provide emotional support and document
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