Selfi

KEP.5B
1814201068
B.INGGRIS III

ASSESSMENT OF
NEUROBEHAVIOUR
SYSTEMS
Definition of Nerve Physical
Examination
The human body will be in a healthy
condition if it is able to respond appropriately to
environmental changes in a coordinated manner. The
body needs good coordination. One of the
communication systems in the body is the nervous
system. The assessment of the nervous system is one
aspect that is very important to be carried out in order
to determine the right nursing diagnosis and take
appropriate treatment actions.
 The neurological examination consists of two
important stages, namely an assessment in the form
of an interview related to the client's medical history
related to the nervous system such as a history of
hypertension, stroke, inflammation of the brain, or
lining of the brain, the use of drugs and alcohol, and
the use of drugs that are taken regularly.
Purpose of the Physical Examination of
Nerves
aims to evaluate the client's physical
condition in general and also assess whether
there are indications of other diseases besides
neurological disorders. In carrying out a
physical examination of the nervous system a
nurse requires knowledge of the anatomy,
physiology, and pathophysiology of the
nervous system.
Preparation of Neural Physical Examination
E q u i p m e n t
 tools preparation:
› Hammer reflex
› Garputala
› Cotton and stick
› Penlight or small flashlight
› Opthalmoscope
› Sterile needle
› Spatel tongue
› 2 tubes filled with warm and cold water
› Touchable objects such as safety pins or change
› Strong-scented ingredients such as coffee, vanilla or perfume
› Anything that tastes salty, sweet or sour, such as salt, sugar, or vinegar
› Check clothes
› Gloves
 For the examiner
Wash hands before and after the procedure,
adjust the sequence of examinations to the
general condition of the client, begin
physical examination from the initial
contact with the client and use general
precaution, the method used by cepalo
cadral or distal to proximal
Nerve Physical Examination Procedure
Set the client's position, ask the client to sit
on the side of the bed. Observe the client's
dress, posture, facial expression and
speech, intonation, loud and soft, choice of
words and ease of responding to questions.
Assess the client's ability to think
abstractly
 Cranial Nerves
 Function of cranial nerves I (N Olvaktorius)
 Function of cranial nerves II (N. Optic)
 F u n c t i o n o f c r a n i a l n e r v e s I I I , I V, V I
(Oculomotor, Trochlear and Abdusen)
 Function of the V cranial nerves (N.
Trigeminus)
 Function of the VII cranial nerves (N. Facial)
 Motor Functions
Assess gait and balance by observing gait, ease of
walking, and coordination of hand and leg
movements.
 Sensory Function
This examination aims to evaluate the client's
response to several stimuli. The examination should
always ask the client the type of stimulus. The
examination is carried out by giving a random
stimulus to the client's body part and can be in the
form of a light touch such as cotton
 Examined Reflexes
 Refleks patella
 Refleks biceps
 Refleks triceps
Angiografi

See firsthand the blood vessel system of the

brain. The contrast agent is introduced through the
artery. Usually in the carotid artery and vertebral
artery, or perhaps the brchial artery and femoral
artery
PATHOPHYSIOLOGY OF THE
NEUROBEHAVIOUR SYSTEM
HEAD PAIN (SEFALGIA) Headache
is a common symptom that almost everyone
has experienced person, at least episodically
during his lifetime. Headache be part of the
sequelae of increase intracranial pressure,
head injury, brain tumors, eye strain, sinusitis,
changes in the atmosphere, food allergies, and
so on. The number of etiological factors that
may cause headaches will not be available
end.
STROKE

Basic Concept of Stroke General

Definition of Stroke Stroke is a loss of brain
function caused by stopping supply blood to
parts of the brain, usually an accumulation of
cerebrovascular disease for several years
(Smeltzer, 2001).
Stroke Classification
 Non-haemorrhage / ischemic / infarction
 Hemorrhagic stroke
Risk Factors for Stroke
1. Hypertension is a potential risk factor for stroke.
2. Diabetes mellitus is a risk factor for stroke, namely with
increased atherogenesis. CHAPTER 2 — Pathophysiology of
the Neurobehaviour System 43
3. Heart / cardiovascular disease has the potential to cause
stroke. These risk factors will give rise to cerebral embolism of
origin from the heart.
4. Normal high hematocrit levels associated with infarction
cerebral.
7. Oral contraceptives, increase by accompanying hypertension,
age at over 35 years, a smoker, and high estrogen levels.
8. Excessive or long-term drop in blood pressure can cause
generalized cerebral ischemia.
Etiology
 Cerebral thrombosis
Cerebral arteriosclerosis and cerebral
circulation slowdown is the main cause of
cerebral thrombosis which is the cause
most general of stroke.
 Cerebral embolism
The embolus usually blocks the middle
cerebral artery or its branches, impairing
the cerebral circulation.
Pathophysiology

According to Long (1996), the brain is

very dependent on oxygen and not have
oxygen reserves. When anoxia occurs as it
happens in CVA, metabolism in the brain
immediately changes, cell death and
permanent damage can occur in 3 to 10
minutes. Every condition which causes
changes in brain perfusion will lead to
hypoxia or anoxia. Hypoxia causes brain
ischemia.
Clinical Manifestations

 Visual field deficit

 Motor deficit

Physical examination
 Open the eyes Opening
 Speech ability
Stroke Prognosis
1. Level of consciousness: conscious 16% died, 39%
somnolence died, stupor 71% died, and if coma 100% died.
2. Age: at age 70 or older, the mortality rates increase
sharp.
3. Gender: more men (16%) died than female (39%). 50
Neurobehavior System
4. Blood pressure: high blood pressure has a poor
prognosis.
5. Other: quick and precise help.
Stroke Management

According to Harsono (1996), mortality and

neurological deteriosasi week the first ischemic
stroke occurs due to brain edema. Edema of the brain
occurs within hours of ischemic stroke and reaches its
peak 24–96 hours.
Supporting investigation

 CT scan of the head

 Examination of lumbar puncture.
 Electrocardiography (EKG).

Complications
complications that occur in stroke patients
namely as follows.
a. Cerebral hypoxia is minimized by providing
oxygenation.
b. Decreased cerebral blood.
c. Cerebral embolism.(Scharfstein & Gaurf, 2013)
TERIMAKASIH