Neurologic System

Pages 642 – 653

Dyana M. M. Saplan, RN, MAN

The Neurologic system
A thorough neurologic examination may take 1 – 3 hrs 3 major considerations determine the extent of neurologic exam:
Client’s chief complaints, Client’s physical condition (LOC and ability to ambulate) – require movement and coordination of extremities, Client’s willingness to participate and cooperate
Dyana M. M. Saplan, RN, MAN

Neurologic assessment includes:
Mental status including LOC, Cranial nerves, Reflexes, Motor function, and Sensory function

Parts of neuro assessment performed thruout hlth exam – Nsg. Hx, gen. appearance Nurse assesses cranial nerve fxns:
CN II, III, IV, V, VI – assessed w/ the eyes and vision CN VIII – assessed w/ the ears and hearing
Dyana M. M. Saplan, RN, MAN

Mental status Reveals client’s general cerebral fxn, w/c include:
Intellectual (cognitive) Emotional (affective)

Major areas of mental status assessment include:
Language Orientation Memory Attention span and calculation
Dyana M. M. Saplan, RN, MAN

Language
Aphasia
any defects or loss of power to express oneself by speech, or writing, or signs to comprehend spoken or written language due to a disease or injury of the cerebral cortex Sensory or receptive aphasia – loss of the ability to comprehend written or spoken words
Auditory (acoustic) aphasia – loss of ability to comprehend symbolic content associated w/ sounds Visual aphasia – loss of ability to understand printed or written figures

Dyana M. M. Saplan, RN, MAN

Language
Motor or expressive aphasia
involve loss of power to express oneself by writing, making signs, or speaking Clients may find that eventho’ they can recall words, they have lost the ability to combine speech sounds into words

Dyana M. M. Saplan, RN, MAN

Orientation
Determines client’s ability to recognize other persons, awareness of when and where they presently are, and who they are Orientation to PERSON, TIME, PLACE, and SELF

Dyana M. M. Saplan, RN, MAN

Memory
Nurse assesses the client’s:
Immediate recall – information presented seconds previously, Recent memory – events or information from earlier in the day or examination, Remote/Long-term memory – knowledge recalled from months or years ago

Listen for lapses in memory; ask about difficulty w/ memory

Dyana M. M. Saplan, RN, MAN

Attention Span and Calculation
Determines client’s ability to focus on a mental task that is expected to be ale to be performed by persons of normal intelligence test the ability to concentrate or attention span by asking the client to recite the alphabet and count backward from 100 Test the client to subtract 7 or 3 progressively from 100 = Serial Sevens or

Serial Threes
Dyana M. M. Saplan, RN, MAN

Level of Consciousness (LOC) Can lie anywhere along a continuum from a state of alertness to coma Apply the Glasgow Coma Scale (GCS/NVS): eye response, motor response, and verbal response
GCS score of 15 pts. = alert and completely oriented Score of 7 or less = comatose client
Dyana M. M. Saplan, RN, MAN

Glasgow Coma scale
Faculty Response Measured Eye opening •Spontaneous •To verbal command •To pain •No response
Dyana M. M. Saplan, RN, MAN

Score 4 3 2 1

Glasgow Coma scale
Faculty Measured Response Score

Motor response

•To verbal command •Localizes pain •Flexes and withdraws •Flexes abnormally •Extends abnormally •No response

6 5 4 3 2 1

Dyana M. M. Saplan, RN, MAN

Glasgow Coma scale
Faculty Measured Verbal response Response
•Oriented, converses •Disoriented, converses •Uses inappropriate words •Makes incomprehensible sounds •No response

Score
5 4 3 2 1

TOTAL
Dyana M. M. Saplan, RN, MAN

15

Cranial Nerves Nurse needs to be aware of specific fxn and assessment methods for each cranial nerve to detect abnormalities Test each nerve not already evaluated in another component of the health assessment

Dyana M. M. Saplan, RN, MAN

12 cranial nerves
I – Olfactory (smell) II – Optic (vision) III – Occulomotor (EOM) IV – Trochlear (EOM) V – Trigeminal (Sensation) VI – Abducens (EOM) VII – Facial (expression, taste) VIII – Auditory (equilibrium, hearing)

IX - Glossopharyngeal (swallowing, taste) X – Vagus (sensation of pharynx and larynx; swallowing; vocal chord movement) XI – Accessory (head movement; shrugging of shoulders) XII – Hypoglossal (protrusion of tongue; up/down, side - side movement)

Dyana M. M. Saplan, RN, MAN

Reflexes
Automatic response of the body to a stimulus Tested using percussion hammer Scale:
0 – No reflex response +1 – Minimal activity (hypoactive) +2 – Normal response +3 – More active than normal +4 – Maximal activity (hyperactive)
Dyana M. M. Saplan, RN, MAN

Reflexes tested:
BICEPS REFLEX
tests the spinal cord level C-5 and C-6

TRICEPS REFLEX
tests the spinal cord level C-7 and C-8

Dyana M. M. Saplan, RN, MAN

Reflexes
BRACHIORADIAL IS REFLEX
tests the spinal cord level C-3 and C-4

PATELLAR
tests the spinal cord level L-2, L-3, L-4

Dyana M. M. Saplan, RN, MAN

Reflexes
ACHILLES REFLEX
tests the spinal cord level S-1, S-2

PLANTAR (BABINSKI) REFLEX
negative babinski – all five toes bend downward (+) Babinski – toes spread outward and the big toe moves upward.

Dyana M. M. Saplan, RN, MAN

Motor function
Evaluates proprioception and cerebellar function Structures involved:
Proprioceptors Posterior columns of the spinal cord Cerebellum – helps control posture; acts w/
cerebral cortex = smooth and coordinated body movements; controls skeletal muscles = equilibrium Vestibular apparatus (innervated by cranial nerve VIII) in the labyrinth of the inner ear
Dyana M. M. Saplan, RN, MAN

Proprioceptors
Sensory nerve terminals, occurring chiefly in the:
Muscles, Tendons, Joints, Internal ear

That give information about movements and position of the body

Dyana M. M. Saplan, RN, MAN

Motor function
Gross Motor and Balance Tests
Generally Romberg test and one other gross motor function and balance tests are used

Walking Gait
Ask client to walk across the room and back, assess client’s gait N: Has upright posture and steady gait with opposing arm swing; walks unaided, maintaining balance D: poor posture and unsteady, irregular staggering gait with stance, bends legs only from hips, has rigid or no arm movements
Dyana M. M. Saplan, RN, MAN

Gross Motor and Balance Tests

Romberg Test
N: Negative Romberg – may sway slightly but is able to maintain upright posture and foot stance D: Positive Romberg: cannot maintain foot stance; moves the feet apart to maintain stance
Cannot maintain balance w/ eyes shut = sensory ataxia (lack of coordination of the voluntary muscles) Balance cannot be maintained whether the eyes are open or shut = cerebellar ataxia
Dyana M. M. Saplan, RN, MAN

Gross Motor and Balance Tests

Standing on One Foot with Eyes Closed
N: Maintains stance for @ least 5 secs. D: cannot maintain stance for 5 secs.

Heel-Toe Walking
N: Maintains heel-toe walking along a straight line D: assumes wider foot gait to stay upright

Toe or Heel walking
Able to walk several steps on heels or toes
Dyana M. M. Saplan, RN, MAN

Fine Motor Tests for Upper Ext.

Finger-To-Nose Test
N: Repeatedly and rhythmically touches the nose D: misses the nose or slow response

Alternating Supination and Pronation of Hands on Knees
Can alternately supinate and pronate hands @ rapid pace Slow clumsy movements and irregular timing; difficulty alternating from supination to pronation
Dyana M. M. Saplan, RN, MAN

Fine Motor Tests for Upper Ext. Finger to Nose and to the Nurse’s Finger Fingers to Fingers Fingers to Thumb (same hand)

Dyana M. M. Saplan, RN, MAN

Fine Motor Tests for Lower Ext.
Heel Down Opposite Shin Toe or Ball of Foot to the Nurse’s Finger

Dyana M. M. Saplan, RN, MAN

Sensory Function
Touch Pain Temperature Position, and Tactile discrimination

Dyana M. M. Saplan, RN, MAN

Assessing Sensory Function
Light-Touch Sensation
Compare light-touch sensation of symmetric areas of the body
R: sensitivity to touch varies among different skin areas

Pain sensation
“sharp,” “dull,” “don’t know” – using broken tongue depressor

Dyana M. M. Saplan, RN, MAN

Pain and Light-Touch Sensation

Dyana M. M. Saplan, RN, MAN

Assessing Sensory Function
Temperature sensation
Not routinely tested if pain sensation is WNL If pain sensation abnormal – sensitivity to temperature may prove more reliable Touch skin areas w/ test tubes filled w/ hot or cold water Have client respond by saying, “hot,” “cold,” “don’t know”

Dyana M. M. Saplan, RN, MAN

Assessing Sensory Function
Position or Kinesthetic Sensation
Middle fingers and the large toes are tested for kinesthetic sensation (sense of position)

Dyana M. M. Saplan, RN, MAN

Tactile Discrimination
For all tests, client’s eyes need to be closed

One- and Two-Point Discrimination
Alternately stimulate skin w/ 2 pins simultaneously, and then w/ one pin Ask client whether he feels 1 or 2 pinpricks

Stereognosis
Ability to recognize objects by touching them Client w/ motor impairment of the hand – write a number or letter on client’s palm, using blunt instrument, ask to identify = GRAPHESTHESIA
Dyana M. M. Saplan, RN, MAN

Graphesthesia and Stereognosis

Dyana M. M. Saplan, RN, MAN

Extinction phenomenon
Simultaneously stimulate 2 symmetric areas of the body
Thighs, cheeks, arms, or hands

Dyana M. M. Saplan, RN, MAN

Lifespan Considerations
Infants
Reflexes commonly tested in newborns:
Rooting Sucking Tonic neck (fencer’s pose) Palmar grasp Stepping Moro

Most of these reflexes disappear @ 4 – 6 months
Dyana M. M. Saplan, RN, MAN

Infantile Reflexes

Dyana M. M. Saplan, RN, MAN

Infantile Reflexes

Dyana M. M. Saplan, RN, MAN

Children
Present procedures as games whenever possible (+) Babinski – abnormal after child ambulates or @ age 2 Note the child’s ability to understand and follow directions. Assess immediate recall or recent memory by using names of cartoon characters.
Normal recall in children is one less than age in years

Assess for signs of hyperactivity or abnormally short attention span
Dyana M. M. Saplan, RN, MAN

Testing Babinski Reflex

Dyana M. M. Saplan, RN, MAN

Children
Should be able to walk backward by age 2 balance on one foot for 5 seconds by age 4 heel-toe walk by age 5, and heel-toe walk backward by age 6. Romberg Test is appropriate over age 3

Dyana M. M. Saplan, RN, MAN

Elders
A full neurologic assessment can be lengthy.
Conduct in several sessions if indicated and cease the tests if the client is noticeably fatigued.

A decline in mental status is not a normal result of aging.
Changes are more the result of physical or physiologic disorders (e.g., fever, fluid and electrolyte imbalances, medications)
Dyana M. M. Saplan, RN, MAN

Elders
Intelligence and learning ability are unaltered with age.
Many factors, however, inhibit learning (e.g., anxiety, illness, pain, cultural barrier)

Because old age is often associated with loss of support persons, depression is a common disorder
Mood changes, weight loss, anorexia, constipation and early morning awakening may manifest it
Dyana M. M. Saplan, RN, MAN

Elders
As a person ages, reflex responses may become less intense. Many elderly clients may have some impairment of hearing, vision, smell, temperature and pain sensation, memory and mental endurance. Coordination changes, including a reduced speed of fine finger movements. Standing balance remains intact, and Romberg’s Test remains negative. Reflex responses may slightly increase or decrease. Many show loss of Achilles reflex, and the plantar reflex may be difficult to elicit.

Dyana M. M. Saplan, RN, MAN

Achilles reflexes

Dyana M. M. Saplan, RN, MAN

Elders
When testing sensory function, the nurse needs to give the older client time to respond.
Normally, older clients have unaltered perception of light touch and superficial pain, decreased perception of deep pain, and decreased perception of temperature stimuli. May also reveal a decrease or absence of position sense in the large toes
Dyana M. M. Saplan, RN, MAN

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Dyana M. M. Saplan, RN, MAN

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