Module 07: Neuromuscular Assessment (Part 01) Flashcards
Under the neuromuscular assessment, what should the nurse observe as per general appearance and survey?
(1) Hygiene:
(a)Nails clean and trimmed; hair clean and combed
(b) Appearance – well kept (clean clothing,
appropriate for weather)
(2) Coherence
(a) Eye contact present
(b) Understandable speech
(c) Ability to follow instructions
(3) Mood and affect
(a) Subjective and objective
Under the neuromuscular assessment when observing the general appearance and survey, poor hygiene is often associated with what?
(a) Depression
(b) Alzheimer’s
(c) Schizophrenia
Under the neuromuscular assessment when observing the general appearance and survey, meticulous finicky grooming is often associated with what?
Obsessive Compulsive Disorder
Under the neuromuscular assessment when observing the general appearance and survey, poor eye contact is often associated with what?
Depression
Under the neuromuscular assessment when observing the general appearance and survey, what is often observed among patients with Parkinson’s disease?
Mask like expression
Under the neuromuscular assessment when observing the general appearance and survey, extreme anger or happiness is often associated with what?
Anxiety
Under the neuromuscular assessment when observing the general appearance and survey, slow repetitive speech is often associated with what?
(a) Parkinson’s disease
(b) Depression
Under the neuromuscular assessment when observing the general appearance and survey, loud and rapid speech is often associated with what?
Maniac Disorder
When assessing the level of consciousness, in this the patient possesses awareness to self and environment; focused response verbally with eye contact.
Alertness
When assessing the level of consciousness, in this, the patient is drowsy, can open eyes and keep eye contact, responds when spoken to a loud voice but still falls back to sleep.
Lethargic
When assessing the level of consciousness, in this, the patient possesses decreased alertness needs to be shaken gently, responds verbally but somewhat confused with short attention span minimal eye contact.
Obtunded
When assessing the level of consciousness, in this, the patient is arousable only to painful stimuli, slow to almost no verbal stimuli; responsiveness stops when stimulus stop minimal awareness to self and environment.
Stuporous
This scale is often utilized to assess the patient’s mental status under the neuromuscular assessment. This is composed by the (a) eye opening response, (b) best verbal response, and (c) best motor response.
Glasgow coma scale
When assessing the level of consciousness, in this, the patient is unresponsive to painful stimuli, unarousable to any stimuli, eyes closed.
Comatose
The Glasgow Coma Scale is composed of what?
(1) Eye opening response
(2) Verbal Response
(3) Motor Response
What is the best response under the Glasgow Coma Scale?
15
What is the grade of a comatose client under the Glasgow Coma Scale?
Eight (8) or less
What is the grade of a patient who is totally unresponsive under the Glasgow Coma Scale?
Three (3)
How should the nurse assess the patient’s orientation?
(a) Person: name, nickname
(b) Time: ask “what is the year? Month of the year? What day of the week?”
(c) Place: ask “where are you now?” city?
Region? Grocery store? Hospital?
How should the nurse assess the patient’s memory under the neuromuscular assessment?
(a) Recall three (3) words
(b) Instruct patient by saying: “I am going to say three words” Orange, paper, and table
(c) Have the patient recite them to help words register in their mind; may repeat until patient has learned the 3 words
(d) Ask patient after a few minutes (15 min), “What were those 3 words I asked you to remember”
What are some questions that the nurse can ask when assessing for the patient’s short term recall?
What did you eat this breakfast? (validate answers with family or sitter)
What are some questions that the nurse can ask when assessing for the patient’s long term recall?
Where did you graduate (or married)? When is your birthday?
When assessing the patient’s short term recall, the inability to remember recent events may be associated with what?
(1) Dementia
(2) Delirium
(3) Depression
(4) Anxiety
When assessing the patient’s long term recall, the inability to remember past events may be associated with what?
(1) MVA injury
(2) Lesion in the cerebral cortex or hippocampus
How should the nurse assess the patient’s concentration or focus?
(a) Give patient calculation of simple Math (2 +3 =5)
(b) Ask patient to count backwards (start at 100, 99, 98 ….)
What are several questions that the nurse can ask when assessing the patient’s reasoning under the neuromuscular assessment?
(a) What will you do if your neighbor’s letter was accidentally delivered to your address?
(b) What would you do if you found a wallet in a grocery store?
(c) Explain the proverb - (give a proverb that is familiar to the patient)
Where do the two (2) axons of the olfactory nerve originate?
From the cell bodies of the cerebrum (temporal lobe)
Where do the two (2) axons of the olfactory nerve terminate?
They terminate at the olfactory bulb just above the ethmoid bone and below the frontal lobe.
How should the nurse assess the patient’s CN 1 (olfactory nerve)?
Assessment of Smell
Procedure:
(1) Prepare types of scents familiar to patient
(2) Instruct patient to close his/her eyes
(3) Instruct Patient to identify the scent with one side of the nose closed (one at a time). May use lemon, coffee or scented soap familiar to/
Where does the CN II or the optic nerve start?
It starts at the optic disk, which is a group of cells in the retinal tissue at the back of the eyes.
This is when the optic nerve (CN II) cross paths with the opposite optic nerve to form a X shaped structure called ________________.
Optic Chiasm
When assessing the patient’s visual acuity, how far should the Snellen’s Chart be placed away from the patient’s point of view?
20 feet
When assessing the patient’s visual acuity, how far should the modified Snellen’s Chart be placed away from the patient’s point of view?
6 feet
When assessing the patient’s visual acuity, how far should the Rosenbaum Chart be placed away from the patient’s point of view?
14 inches
How should the nurse assess the patient’s visual acuity/ Explain the test or the procedure.
(1) Let patient keep eyeglasses on
(2) Ask patient to read the chart with one eye covered
(3) Repeat with the other eye with one eye covered
(4) Ask patient to read with both eyes uncovered
Which cranial nerve is being assessed when examining the patient’s pupillary response to light?
CN III (Oculomotor Nerve)
How should the nurse assess the patient’s CN III (Oculomotor Nerve)?
(1) Instruct patient to look on your eyebrows
(2) Use penlight on the side of one eye and move slowly towards the pupil and watch for subtle, slight movement of pupillary constriction
What is the normal response when assessing the patient’s pupillary response to light?
(1) Pupils equally round, reactive to light and accommodation (PERRLA)
(2) Normal response = 3mm to 2 mm or 4 mm to 3 mm
What is the abnormal response when assessing the patient’s pupillary response to light?
(1) Size: <2 or >4
(2) Unequal size of pupils (Anisocoria)
This condition pertains to when the patient has unequal size of pupils.
Anisocoria
What are the three (3) cranial nerves responsible for the six ocular movements?
(1) CN 3
(2) CN 4
(3) CN 6
Where do CN3, CN4 and CN6 originate?
Originates from the oculomotor nucleus located within the midbrain of them brainstem.
Where do CN3, CN4 and CN6 emerges?
It emerges in the anterior aspect of the midbrain, passing inferiorly to the posterior cerebral artery.
This cranial nerve allows for the movement of the eye muscles such as the constriction of the pupils, focusing of the eyes and elevation of the upper eyelids.
Oculomotor Nerve
What are the muscles involved when it comes to eye or ocular movement?
(1) Inferior oblique
(2) Medial Rectus
(3) Levator Palpebrae
These muscles involved when it comes to ocular movement is responsible for the up and down movement?
Inferior Oblique
These muscles involved when it comes to ocular movement is responsible for the inward and outward movement?
Medial Rectus
These muscles involved when it comes to ocular movement is responsible for the movement of the upper eyelids?
Levator Palpebrae
What procedures are often used to check for the patient’s ocular movements?
Six Cardinal Fields of Gaze (Use the Asterisk or H test)
How should the nurse perform the procedure when assessing for the patient’s Six Cardinal Fields of Gaze (Use the Asterisk or H test)?
(1) Distance from patient at least 2 feet
(2) Using your finger or a penlight, trace an Asterisk or “H” pattern in front of the patient slowly while instructing them to hold their head still.
(3) Make sure only the eyeballs are moving.
(4) Watch for uncoordinated movements, twitching of the eyeballs (nystagmus)
This condition is often associated when the patient has uncoordinated movements or twitching of the eyelids. This is also observed when the patient has rapid repetitive uncontrolled movements of the eyeballs)
Nystagmus
What are the normal findings when assessing for the patient’s ocular movement?
Eves coordinated, smooth motion of the eyes and no nystagmus
What are the abnormal findings when assessing for the patient’s ocular movement?
(a) Uncoordinated movement
(b) Positive for “nystagmus” (rapid repetitive uncontrolled movements of the eyeballs)
(c) Paralysis or lesion can cause difficulty of moving the eye downward and towards the nose or internal rotation of the eyes -
Superior oblique muscle (CN4 Trochlear)
(d)) Ptosis Rt/Lt eyelid (CN3-droopy eyelid)
What cranial nerve is damaged when paralysis or lesion can cause difficulty of moving the eye downward and towards the nose or internal rotation of the eyes?
Superior oblique muscle (CN4 Trochlear)
What cranial nerve is affected when the patient has a droopy eyelid (Ptosis)?
CN3
This condition is often associated when the patient has a droopy eyelid both right and left or either; thus affecting the CN3?
Ptosis
This is part of the six ocular movements but is more specific with the CN VI (Abducens).
Lateral Movement
What are the normal findings when probing into the lateral movement of the eyes?
Eyes coordinated upon lateral movement.
What are the abnormal findings when probing into the lateral movement of the eyes?
Nerve lesion or paralysis of the eye muscle which causes eye to deviate medially causing double vision.
Which cranial nerve is responsible for the patient’s peripheral vision?
CN 3
The loss of peripheral vision is often caused by what?
Loss of Peripheral vision are caused by many disease conditions such as migraines, cataracts, glaucoma, stroke, and detached retina.
How should the nurse probe into the peripheral vision of the patient?
(1) Instruct patient to look straight to the examiner
(2) Instruct patient to focus on the object without moving head and eyes
(3) Assess visual fields by moving the object; start at the periphery going towards the center or vice versa
What is the normal finding when examining or assessing the patient’s peripheral vision?
Can visualize as it approaches the periphery
This condition pertains to the patent loss of peripheral vision and has the inability to see object at the periphery.
Tunnel Vision
Which cranial nerve is being assessed when examining the convergence of the patients’ eyes?
CN III (oculomotor) and CN IV (trochlear)
How should the nurse perform the convergence test?
(1) Distance of the object 3-4feetaway.
(2) Instruct patient to follow the object slowly as it touches his/her nose
What is the normal response when examining the convergence of the patient’s eyes?
Eyeballs converge on the nose at the same time. Pupils constrict as the eyes focus on the object
What is the abnormal response when examining the convergence of the patient’s eyes?
Unequal response of pupils; No focus of Rt eye or Lt eye
Which cranial nerve is affected when examining or conducting the sensory ability test (sharp or dull)?
CN V (Trigeminal)
How should the nurse conduct the sensory ability test (sharp or dull)?
(1) Use paperclip of hammer (with sharp end)
(2) Instruct patient to close both eyes
(3) Apply sharp or dull sensation to face at forehead, cheek and chin; alternate Lt then Rt side of face
(4) Ask patient to identify if sensation is sharp or dull
What should be the normal response when examining the patient’s sensory ability?
Able to identify sharp and dull sensations to forehead, cheek and chin
This nerve disorder is often associated with the inability to identify facial sensations.
Trigeminal Neuralgia
This nerve disorder is often associated with intense pain or loss of tactile sensation of the face, as well as weakness in biting or clenching of the teeth.
Tic Douloreux
This condition pertains to the swelling of the optic nerve which results in blurred optic disc margins and dilated, pulsing veins. This occurs due to increased intercranial pressure from an intercranial hemorrhage or brain tumors.
Papilledema
This condition occurs with brain tumors.
Optic atrophy
This condition pertains to the drooping of the eyelid and is seen in weak eye muscles such as myasthenia gravis.
Ptosis
This condition is associated with the paralysis of the oculomotor, trochlear or abducens nerves.
Paralytic Strabismus
Which cranial nerve is damaged when the patient as an abnormally dilated pupil?
Oculomotor (CN3) paralysis
This condition is often associated with CNS syphilis, meningitis, brain tumor, alcoholism.
Argyll Robertson pupils
This condition is often associated with narcotics abuse or damage to the pons.
Constricted fixed pupils
This condition is often associated to a patient whose pupil is unresponsive to light or accommodation.
Unilaterally Dilated pupil (damage to the CN3 (oculomotor).
How should the nurse enact the examination of the patient’s motor response as per the assessment of the CN V or Trigeminal Nerve?
Palpate masseter muscles and temporal muscles as the patient clench teeth
What is the normal findings when examining the the patient’s motor response as per the assessment of the CN V or Trigeminal Nerve?
Muscles contract bilaterally
What is the abnormal findings when examining the the patient’s motor response as per the assessment of the CN V or Trigeminal Nerve?
Asymmetrical or no muscle contraction. Positive pain or weakness bilateral or unilateral
What is the sensory function of the facial nerve (CN7)?
Taste anterior 2/3 of the tongue. Sense of taste, from anterior 2/3 of tongue, sensory from external ear and palate.
What is the motor function of the facial nerve (CN7)?
Facial expressions. Muscles of the facial expression, throat and middle
ear.
How should the nurse assess the facial nerve (CN7) of the patient?
Ask patient to do the following facial grimaces:
(1) Frown
(2) Smile (teeth showing)
(3) Puff cheeks
What is the parasympathetic function of the facial nerve (CN7)?
Submandibular and sublingual salivary glands, lacrimal glands and nasal cavity
What is the normal findings or response of the patient when assessing the facial nerve (CN7)?
Symmetrical facial expressions. No drooping; Normal salivation
What is the abnormal findings or response of the patient when assessing the facial nerve (CN7)?
Asymmetrical facial expressions. Facial paralysis (Bell’s palsy) with drooping on one side of face (Rt or Lt); Loss of taste (2/3 anterior tongue) and decreased salivation
This condition is defined as a peripheral injury of CN7. This is known as the paralysis of the lower part of the face on the opposite side affected and may be seen with a central lesion that affects the upper motor neurons such as stroke.
Bell’s Palsy
Where does the CN7 or Vestibulocochlear (Acoustic) originate?
These originates between the
pons and the medullar oblongata, by two roots, vestibular and cochlear, emerging behind the facial nerve and in front of the inferior cerebellar peduncle.
Which cranial nerve is associated with the calibrated finger rub auditory test?
Cranial Nerve 8 or the Vestibulocochlear Nerve
How should the nurse perform the calibrated finger rub auditory test?
(1) Perform finger rub test one at a time at least two times per ear.
(2) Instruct patient to close both eyes and identify if sound is coming from the left or right ear.
Vibratory sound lateralizes to good ear in ____________ . Air conduction is longer than bone conduction, but not twice as long.
Sensorineural loss
Where does the vagus nerve run from?
Runs from the brain through the face, thorax, and the abdomen.
Where does the vagus nerve (CN10) exit?
Exits the brain from the Medulla Oblongata of the brain stem and travels laterally; exits the skull through the jugular foramen.
What is the sensory function of the vagus nerve (CN10)?
Inferior pharynx, uvula, larynx, thoracic and abdominal organs sense of taste posterior tongue
What is the motor function of the vagus nerve (CN10)?
Soft palate and voice production
What is the parasympathetic function of the vagus nerve (CN10)?
Thoracic and abdominal muscles
How should the nurse examine the patient’s cranial nerve number 10 or the Vagus nerve?
(1) Prepare: gloves, tongue depressor, and penlight
(2) Ask patient to hyperextend neck, open mouth, and say a long “Ahhh”
(3) Check movement of the uvula, locate the tonsil and oropharynx
What is the normal findings when examining the patient’s cranial nerve number 10 or the Vagus nerve?
Positive “gag reflex”
Uvula vibrates with “Ah”
What is the abnormal findings when examining the patient’s cranial nerve number 10 or the Vagus nerve?
(1) Negative “gag reflex”
(2) Difficulty swallowing
(3) Hoarseness
(4) Uvula deviates from site of dysfunction
Unilateral rising of the soft palate and deviation of the uvula to the normal side are seen with a unilateral lesion of ____________________.
Cranial Nerve X (Vagus)
Dysphagia or hoarseness may indicate a lesion of cranial nerve?
Cranial nerve IX (Glossopharyngeal) or X (Vagus) or other neurologic Disorder
Asymmetric muscle contraction or drooping of the shoulder may be seen with paralysis or muscle weakness due to neck injury or ________________.
Torticollis
Where does the CN XII or Hypoglossal nerve originate?
Originates from the medulla and travels caudally and dorsally to the tongue. It is mainly an efferent nerve for the tongue musculature.
How should the nurse conduct the test for the movement, strength and mobility of the tongue?
Instruct patient to protrude the tongue out, move tongue up, down, left, and right side.
Which cranial nerve is associated with the tongue movement?
CN XII or Hypoglossal nerve
What is the normal findings when examining the movement, strength and mobility of the tongue (CN XII or Hypoglossal nerve)?
Symmetrical tongue with smooth outward movement and bilateral strength
What is the abnormal findings when examining the movement, strength and mobility of the tongue (CN XII or Hypoglossal nerve)?
Asymmetrical tongue, deviation to one side and no strength
This cranial nerve is formed by the fibers from the medulla oblongata (cranial root and by the fibers from C1 to C4 (spinal root).
CN XI (11) Spinal Accessory Muscles
Where does the CN XI (11) Spinal Accessory Muscles exit?
Exits the medulla below the vagal nerve. Its fibers join the vagal nerve.
What are the spinal accessory muscles associated with the motor response CN XI (11) ?
(1) Sternocleidomastoid muscle
(2) Trapezius muscle (ROM of neck and scapula)
How should the nurse assess the strength of the patient’s sternocleidomastoid muscle?
(a)> Instruct patient to turn head against your hand with resistance
(b) Perform left side of the face and then the right side
How should the nurse assess the strength of the patient’s trapezius muscle?
(a) Instruct patient to shrug one side of shoulder as you apply pressure
(b) Repeat on the other shoulder and then do on both shoulders.
This is seen in many diseases of the lower motor neurons or muscle disorders.
Muscle atrophy
This pertains to the rapid twitching of the resting muscle seen in the lower motor neuron disease or fatigue.
Fasciculation
This condition pertains to the twitch of the face, head or shoulder. This is the unusual bizarre face tongue jaw or lip movements from chronic psychosis or long term use of the psychotropic drugs.
Tic
This condition pertains to the rhythmic or oscillating movements from Parkinson’s disease, cerebellar disease, multiple sclerosis with movement, hyperthyroidism, or anxiety,
Tremors
This condition is often associated with slow and twisting movements in the extremities of the face.
Cerebral Palsy
This condition is often associated by brief rapid irregular and jerky movements at rest.
Huntington’s disease
