Neurological System

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  1. Nervous System
    • Central Nervous System (CNS)
    • Brain and Spinal Cord 

    • Peripheral Nervous System
    • Cranial Nerves
    • Spinal Nerves 
    • Autonomic Nervous System (ANS)
  2. Central Nervous System (CNS) 
    Brain and Spinal Cord
    • Brain 
    • Cerebrum- ability to think and reason 
    • Divided into 4 lobes and 2 hemispheres
    • Parietal lobe
    • Occipital lobe
    • Temporal lobe
    • Frontal lobe 
    • Right and Left hemispheres
    • Right- creative 
    • Left- artistic
  3. Cerebrum
    • Cerebrum contains: 
    • Gray and white matter, basal ganglia- automatic movement 

    Thalamus- motor and sensory stimuli

    • Hypothalamus - controls vital functions; maintains hemostasis 
    • Temperature 
    • Blood Pressure 
    • Pulse 
    • Pituitary hormone- sleep and wake cycle 
    • water balance 

    Limbic system- survival behavior - (emotional survival behavior)
  4. Cerebellum
    Major motor and sensory pathway: 

    • Coordinates voluntary movement 
    • Posture 
    • Muscle tone
    • Maintains equilibrium
  5. Brainstem: Medulla, Pons, Midbrain
    • Function: 
    • Regulates heart rate
    • Regulates Breathing 
    • Swallowing, hiccup, cough, sneeze, vomiting 
    • pathway of communication between high and low brain centers
  6. Spinal Cord
    Primary pathway for messages to travel between brain and peripheral parts of body 

    Contains sensory (sense) and Motor (movement) pathways
  7. Peripheral Nervous System: Cranial and Spinal Nerve, ANS
    • Spinal= sensory and motor
    • Cranial=12 pairs, originate in brain, sensory and motor
    • ANS= involuntary function of cardiac and smooth muscle, glands;
    • sympathetic (fight or flight) 
    • parasympathetic (rest and digest)
  8. Assessment: Physical Examination
    Begin Physical Exam with highest level of function and progress to lowest level 

  9. Assessment: Neurological System
    • Mental Status and Speech 
    • Cranial Nerve Function 
    • Sensory Function 
    • Motor Function 
    • Reflexes
  10. Mental Status and Speech
    Level of consciousness (LOC) 

    Assess arousal and orientation 

    Change in LOC = earliest and most sensitive indicator of Neuro status

    • Can you state your name? Where are you? What day is it? 
    • Day, date and year
  11. Level of Consciousness: Terms used to Describe
    Alert or wakefulness- appreciate the environment and responds quickly to stimuli 

    Confusion- disoriented to time, place, or person; has shortened attention span; shows poor memory; or has difficulty following commands 

    Drowsiness:lethargy, obtunded- respond to stimuli appropriately but with delay and slowness; may respond to some but not all

    Stupor- patient is unresponsive and can be aroused only briefly by vigorous, repeated stimulation. 

    Coma- unresponsive and generally cannot be aroused

    Orientation to time- from date of birth to current time, day, date. Orientation to time has been correlated with future decline 

    Orientation to place- ask, where are you? This is sometimes narrowed down to address, or to floor or room number.

    Appearance and Behavior 

    Communication (Speech/language)
  12. Assessment of consciousness: Applying Stimulation
    Order of Stimulation 

    • Spontaneous 
    • Normal voice 
    • Loud voice 
    • Tactile (touch)
    • Noxious stimulation (pain)
  13. Glasgow Coma Scale
    standardized assessment tool that assesses LOC

    • Assess for:
    • Eye opening (response)
    • Motor
    • Verbal response 
    • Each parameter is given a score 
    • A score of less than 7 defines coma
  14. Glasgow Coma Scale
    Glasgow Coma Scale for Head Injury 

    • Eye opening 
    • Verbal Response 
    • Best Motor Response
  15. Cognitive Function
    • Memory (recent and remote)
    • Remote- What is your birthday? 
    • Recent- What did you eat for breakfast? 

    Attention span-

    Ability to calculate- count to 20 

    Thought content- patient listen to you and follow direction 

    Abstract reasoning- what do apple, pear, and orange have in common? 

    Judgment, insight- What will you do when in a public building and the fire alarm goes off? 

    Emotional Status 

    • New Learning (Memory) 
    • Brown
    • Honesty 
    • Eye drop 
    • tulip
  16. Pupillary Response
    • size, shape, 
    • Reactivity to light: direct and consensual 
    • PERRLA (Pupil Equal Round React to light and Accommodation)
  17. Abnormal Movement
    • Abnormal reflexes 
    • Posturing 
    • Involuntary movements
  18. Posturing
    Decorticare Posturing (to the core) 

    • Decerebrate posturing- bad )something is wrong with the brainstem)
    • Regulate breathing and heart rate
    • Injury to cerebral cortex
  19. Cranial Nerve (one)
    Olfactory (smell)
    • Sensory 
    • Sense of smell 
    • EX: coffee, tea, soap, and vanilla
  20. Cranial Nerve (two) 
    Optic (Vision)
    • Sensory 
    • Controls visual acuity and peripheral vision 
    • Visual field when looking straight ahead
    • Ex: Snellen Chart 
    • 20/50: At 50 feet you can see what the normal person can see at 50 feet
  21. Cranial Nerve (three) 
    • Motor function 
    • Controls most eye movements, pupil response and eyelid function 
    • Ex: upward, Medial, and downward
  22. Cranial Nerve (four) 
    • Motor function 
    • Control eye movements: 
    • The downward and inward movement 
    • Ex: Both eyes follow symmetry and there is no abnormal movement 
    • 6 Cranial field of gaze 
    • Document: EOMs (Extra occipital movement) intact or parallel tracking
  23. Cranial Nerve (five) 
    • Motor and Sensory function
    • Control motor movements of the jaw
    • Sensation of the face and neck 
    • 3 Devision 
    • opthalmic- forehead 
    • Maxillary- cheek 
    • Mandibular- Jaw 
    • Ex: Touch forehead, cheek and clench teeth
  24. Cranial Nerve(six) 
    Acoustic (Hearing) Equilibrium
    • Sensory function
    • Controls hearing and equilibrium
    • Test hearing ability
  25. Cranial Nerve (seven) 
    Facial (Smile)
    • Motor and sensory function
    • Controls muscles of the face: smile, frown, raise eyebrows, show teeth, puff cheeks
    • Control taste for the anterior 2/3 of tongue smile have the person smile, show their teeth and raise up the eyebrow to make sure all the facial muscles are working 
    • Ex: Sugar and salt and see if they taste both
  26. Cranial Nerve (Eight) 
    Glossopharyngeal (Speech)
    • Motor and sensory fi=unction 
    • Controls pharyngeal movements and swallowing 
    • Controls taste on the posterior 1/3 of the tongue
    • Say "AH", note swallow
  27. Cranial Nerve (Ten)
    Vagus (Defecation)
    • Motor and sensory function 
    • Controls swallowing and speaking, Heart rate, digestion 
    • Controls sensations from the pharynx, carotids. 
    • Gag reflex
    • Test: Listen to patient speaking and swallow
  28. Cranial Nerve (Eleven) 
    Spinal Accessory (Shoulder Shrug)
    • Motor function 
    • Controls movements of the shoulders
    • Trapezius and sternomastoid muscles 
    • Test: Shrug shoulders against your resistance
  29. Trapezius and Sternomastoid Muscles
    Sternomastoid- contracting
  30. Cranial Nerve (Twelve) 
    Hypoglossal (Tongue Movement)
    • Motor function 
    • controls movement and strength of the tongue
    • Test: Ask patient to "stick out your tongue" move it side to side and push against cheek.
  31. Assessment of Sensory Function
    • Screening 
    • Tests intactness of peripheral nerve fibers, sensory tracts and upper cortical discrimination 
    • Compares sensations on different parts of the body 
    • Patient needs to be alert, oriented
    • Try not to have a pattern 
    • If screening identifies an area with altered sensation, identify borders
    • Light Touch 
    • Superficial Pain Sensation 
    • Temperature Sensation
    • Motion and position sense 
    • (kinesthesia) movement of an extremity
  32. Stereognosis
    Ability to recognize familiar objects
  33. Graphesthesia
    Ability to recognize a number or letter by having it traced on the skin
  34. Vibration Sensation
    Placing a tuning fork on a bony prominence
  35. Point Localization
    Ability to sense and locate an area being stimulated
  36. Sensory Extinction
    • Simultaneously touch both sides of the body at the same point
    • How many sensation did you feel and where were they?
  37. Tandem Walking
    Heel to toe walking
  38. Romberg Test
    • Test for balance 
    • Eye open, feet together and arms at the side. Ask the patient to close their eyes and hold their balance.
  39. Motor Function
    • Muscle Mass: Size and bulk 
    • Muscle Tone: resistance of muscles to stretching 
    • Muscle Strength (0 to 5 scale) 
    • Pronator drift
    • Hand grips
    • Pushing against resistance 
    • Report as: patient ability/ 5
  40. Coordination
    • Rapid alternating movements 
    • Point to point testing 
    • Finger to finger test 
    • Heel to shin test
  41. Deep Tendon Reflexes (DTRs)
    • Evalutes intactness of spinal cord, and sensory/ motor functioning 
    • Tendon is struck briskly
    • Reflexes are graded 0-4
    • Report as: patient ability/4
    • 2 is normal
    • 3 and 4 hyperactive
  42. Superficial Reflex: Stimulation of the skin
    • Abdominal Reflex 
    • Stroke the abdomen from the side to the center 
    • Normal: + contraction of the abdominal muscles
  43. Plantar Response: Babinski Reflex
    • Primitive reflex: normal to see in infants 
    • Normal (is a negative response): toes remain still or flexed 
    • Abnormal (is a positive response): Great toe extends and other toes fan 
    • In adults=neurological problem that needs further investigation
  44. Nursing Diagnoses
    • Risk for ineffective cerebral tissue perfusion 
    • Risk for injury 
    • Risk for Aspiration 
    • Impaired Verbal Communication 
    • Impaired Physical Mobility 
    • Confusion (Acute or Chronic)
  45. Care for the Patient with Altered Mental Status
    • Neuro Assessment: identify needs and risks 
    • Reorient at each interaction 
    • Assess safety needs 
    • Room near nurses station
    • 15 minute checks, 1:1 needs
    • Bed alarms, chair alarms
    • Assist with meals: risk of aspiration
    • Assist with ambulation: risk of injury, fall
    • Administer medications
    • improve memory
    • evaluation medications that can cause confusion
  46. Care for Patient with a History of Seizures
    • Neuro assessment 
    • Maintain safe environment 
    • bed in low position 
    • side rails padded 
    • 3 side rails up 
    • airway, suction equipment at bedside 
    • Administer anticonvulsants as ordered. E valuate other meds that can increase seizure activity 
    • If seizure occurs, provide accurate documentation regarding 
    • Aura: pre-seizure activity 
    • Ictal: Activity, time 
    • Postictal: post seizure activity
  47. Care for a patient during a seizure
    • Maintain safety 
    • Move items away from the patient 
    • Assess airways needs and seizure activity 
    • Notify MD
    • Administer anticonvulsants (IV) as ordered 
    • Post seizure 
    • VS including o2 sat 
    • assess risk of injury 
    • provide emotional support 
    • Accurate Documentation
Card Set:
Neurological System
2016-10-10 11:43:52

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