Assessment of the neurological system

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Assessment of the neurological system
2014-04-26 20:09:21

fundamental of nursing
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  1. 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)
  2. 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
  3. Cerebellum
    • Major motor and sensory pathway, coordinates voluntary
    • movements, equilibrium
  4. Brainstem (medulla/pons)
    • Regulates heart rate, breathing and swallowing, coughing.
    • Sensory/motor pathways to and from the cerebral cortex
  5. 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.
  6. 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 
  7. 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
  8. PE of Neurological system
    • - mental statuses and speech
    • - cranial nerves
    • - sensory
    • - motor
    • - reflexes
  9. 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 
  10. 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
  11. 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
  12. MS/LOC 
    • 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. 
  13. MS/LOC
    appearance and behavior
    • Appearance and behavior- are they dressed
    • appropriately for the season- hygiene intact 
  14. MS/LOC
    Communication- clear and articulate
  15. 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
  16. MS/LOC
    pupillary response
    • Pupillary response- PERRLA size shape reactive
    • to light. Consensual
  17. MS/LOC
    abnormal movements
    • Abnormal movements- abn. Reflex posturing,
    • involuntary movements
  18. 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
  19. 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
  20. 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.
  21. 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
  22. CN IV
    • Trochlear- motor
    • Control eye movements downward and inward
  23. 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. 
  24. CN VI
    Abducens- motor

    Controls lateral (side) movements of eye. H test to perform for all three nerves 3,4,6
  25. 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
  26. CN VIII
    Acoustics- sense

    • Controls hearing- whisper test, Weber test (head) and Rinne
    • test ac>bc (turning fork)
  27. CN IX
    Glosspharyngeal- sense/motor

    • Controls pharyngeal and swallowing (motor). Taste on the
    • posterior of the tongue (sense)
  28. 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
  29. 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
  30. CN XII
    Hypoglossal- motor

    • Involves tongue movement. Stick out tongue and move from
    • side to side
  31. 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

  32. Sensory assessment
    • 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. 
  33. 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
  34. 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. 
  35. 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
  36. 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 
  37. 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

    • -      
    • post seizure- VS including O2 stat, assess risk
    • of injury provide emotional support and document