Nervous System Flashcards
- Headache
- Head Injury
- Dizziness
- Seizures
- Tremors
- Weakness
- Coordination
- Numbness or tingling
- Difficulty swallowing
- Older Adult = Changes in vision, memory or confusion
subjective data
- mental status
- cranial nerves
- motor and sensory systems
- reflexes
should be performed on anyone w/ neurologic concerns
recheck anyone w/ deficits
neurologic exam
- appearance: appropriate for environment
- behavior: LOC, awake and alert
- cognition: orientation
recent memory: 24-hr dietary recall
remote memory: 1st job, 1st pets home, historical events - thought process: logical and coherent
- judgement: actions appropriate??
- Mini-Mental Status Exam (MMSE)
Mental status
0-17 severe impairment, 18-23 mild impairment, 27 is normal
MMSE
- alert
- lethargic (somnolent)
- obtunded
- stupor (semi-coma)
- coma
- delirium
- dementia
Level of Consciousness (LOC) terms
Awake or easily aroused. Fully aware of surroundings. Appropriate responses.
Alert
drifts to sleep when not stimulated
Lethargic (somnolent)
Difficult to arouse, confusion when aroused, requires constant stimuli
obtunded
Spontaneous unconscious, Responds to painful stimuli, Non-verbal response to pain
stupor (semi-coma)
Unconscious, no response to stimuli
coma
Inattentive, incoherent, impaired recent memory
delirium
Loss of cognitive and intellectual function. Consciousness intact. Impaired judgement, disorientation, memory loss.
dementia
Oriented to person, place, time, and situation
- what is your name?
- do you know where you are?
- what month is it?
Levels of arousal
- verbal stimuli
- tactile stimuli
- painful stimuli
Sitting erect with no involuntary body movements. Dress and grooming are appropriate for season and setting.
Documentation for normal mental status: Appearance
Alert, appropriate facial expression and fluent, understandable speech. Affect and verbal response are appropriate.
Documentation for normal mental status: Behavior
Oriented to person and place. Cooperative. Recent and Remote memory intact.
Documentation for normal mental status: cognition
Thought process logical and coherent. No suicidal ideation. MMSE score 28.
Documentation for normal mental status: thought process
equipment for physical assessment
- penlight
- tongue blade
- cotton swab
- tuning fork
- percussion hammer
cranial nerves III, IV, VI, XI, XII
motor cranial nerves
cranial nerves I, II, VIII
sensory cranial nerves
cranial nerves V, VII, IX, X
motor and sensory (mixed) cranial nerves
smell
With person’s eyes closed, occlude one nostril and present familiar aromatic substance & repeat with other nostril e.g., coffee, orange, vanilla, soap, or peppermint
Normally person can identify an odor on each side of nose; normally decreased with aging; any asymmetry in sense of smell is important
Cranial nerve I (olfactory)
Visual acuity, visual fields, and ocular fundi
visual acuity = snellen chart
visual fields = “how many fingers I’m holding up?”
ocular fundi = using ophthalmoscope, and defining color, shape, and size of optic disc
papilledema = increased ICP
Cranial nerve II (optic)
EOM, pupil constriction
Eye movement through 6 visual fields of gaze, opening of eyelids, pupil constriction, and lens shape
PERRLA
Ptosis
cranial nerve III (oculomotor)
EOM
Downward and inward movement of the eyes
Strabismus
cranial nerve IV (trochlear)
Corneal reflex; scalp, teeth, and facial sensation; and jaw movement
Motor function: assess muscles of mastication by palpating temporal and masseter muscles as person clenches teeth.
Sensory function: with person’s eyes closed, test light touch sensation
Ophthalmic- Maxillary – Mandibular
cranial nerve V (trigeminal)
EOM
Lateral movement of eyes
Nystagmus is back-&-forth oscillation of eyes
cranial nerve VI (abducens)
facial movement, sense of taste
Motor function: Note mobility and facial symmetry as person responds to requests smile, frown, close eyes tightly (against your attempt to open them), lift eyebrows, show teeth
Have person puff cheeks, then press puffed cheeks in, to see that air escapes equally from both sides
Sensory function: (not tested routinely) Test only when you suspect facial nerve injury
When indicated, test sense of taste by applying cotton applicator covered with solution of sugar, salt, or lemon juice to tongue and ask person to identify taste
cranial nerve VII (facial)
hearing and equilibrium
Test hearing acuity by ability to hear normal conversation and by whispered voice test
Weber and Rinne test (air/bone conduction)
Romberg test-balance: a test used in an exam of neurological function for balance, and also as a test for driving under the influence of an intoxicant
cranial nerve VIII (auditory)
Swallowing, gag response, tongue movement, taste, secretion of saliva
Motor function: Depress tongue with tongue blade, and note pharyngeal movement as person says “ahhh” or yawns; uvula and soft palate should rise in midline, and tonsillar pillars should move medially
Touch posterior pharyngeal wall with tongue blade, and note gag reflex; voice should sound smooth, not strained
Client should be able to talk, swallow, and cough
Sensory function: Check taste: sweet, salty, sour (posterior tongue)
cranial nerve IX (glossopharyngeal)
Sensation of pharynx & larynx; motor activity of swallowing & vocal cords; sensory in cardiac, respiratory, & blood pressure reflexes; peristalsis; digestive secretions
cranial nerve X (vagus)
head movement and shoulder elevation; motor to larynx (speaking)
Examine sternomastoid and trapezius muscles for equal size
Check equal strength by asking person to rotate head against resistance applied to side of chin
Ask person to shrug shoulders against resistance
These movements should feel equally strong on both sides
cranial nerve XI (spinal accessory)
tongue movement
Inspect tongue;
Note forward thrust in midline as person protrudes tongue; move side to side
Ask person to say “light, tight, dynamite,” and note that lingual speech (sounds of letters l, t, d, n) is clear and distinct
cranial nerve XII (hypoglossal)
- muscle tone
- motor function
- balance and gait
- sensation
- reflexes
further assessment
ensure to inspect for size for all muscle groups. compare right size to left size.
assess for atrophy and assess for ROM
muscle tone
Rapid Alternating Movements (RAM)
Finger-Nose-Finger
Heel-to-Shin
motor function
test for ataxia
Romberg’s test
Gait and balance
assessment of proprioception
positive test = loss of balance
ataxia is sensory in nature
Romberg’s test
- stereognosis
- graphesthesia
- point localization
- sensory extinction
Sensation
Place a familiar object in the palm of the client’s hand and have them identify it.
Stereognosis
assess by drawing a number or letter in the palm of a client’s hand and having the client identify what was drawn.
Graphesthesia
touch the skin and withdraw the stimulus quickly. “Put your finger where I touched you.” You can perform this test simultaneously with light touch sensation.
point localization
simultaneously touch both sides of the body at the same point. Ask the client to state how many sensations are felt and where they are felt.
sensory extinction
response is graded on 4-point scale:
4
3
2
1
0
reflexes
very brisk, hyperactive with clonus, indicative of disease
4
brisker than average, may indicate disease
3
Average, normal
2
diminished, low normal, or occurs with reinforcement
1
no response
0
- biceps reflex, C5 to C6
- brachioradialis reflex, C5 to C6
- triceps reflex, C7 to C8
DTR - arm
Support the person’s forearm on yours; place your thumb on biceps tendon and strike a blow on your thumb
Normal response is contraction of biceps muscle and flexion of forearm
Biceps reflex, C5 to C6
Normal response is flexion and supination of forearm
Brachioradialis reflex, C5 to C6
Tell person to let arm “just go dead” as you strike triceps tendon directly just above the elbow
Normal response is extension of forearm
Triceps reflex, C7 to C8
- quadriceps reflex, L2 to L4
- Achilles reflex, L5 to S2
- Babinski
DTR - leg
Let lower legs dangle freely to flex knee and stretch tendons; strike tendon directly just below patella
Normal response is extension of lower leg
Quadriceps reflex, L2 to L4
Position person with knee flexed; hold foot in dorsiflexion and strike Achilles tendon directly
Normal response is foot plantar flexes against your hand
Achilles reflex, L5 to S2
occurs when stimulation of the lateral plantar aspect of the foot leads to extension (dorsiflexion or upward movement) of the big toe (hallux)
there may be fanning of other toes
can be normal in infants
Babinski
test when reflexes hyperactive
Support lower leg in one hand and with other hand, move foot up and down to relax muscle; then stretch muscle by briskly dorsiflexing foot; hold the stretch
Normal response: you feel no further movement
When clonus present, you will note rapid rhythmic contractions of calf muscle and movement of foot
clonus
sucking
rooting
tonic neck (fencing)
Step reflex
palmer
plantar
crawl reflex
moro reflex
reflexes - infant
Some hospitalized persons have head trauma or a neurologic deficit due to systemic disease process
Must be monitored closely for any improvement or deterioration in neurologic status and for any indication of increasing intracranial pressure
Signs of increasing intracranial pressure signal impending cerebral disaster and death and require early and prompt intervention
Eyes open spontaneously to name
Verbal responses makes sense?
Speech is clear and articulate?
Face is symmetric? (facial droop? Ptosis?)
Ability to swallow (unless NPO)?
Motor response is strong and equal bilaterally?
Are Pupils Equal, Round, React to Light and Accommodation?
Muscle strength, R and L (upper-use hand grips) (Lower-flex and push hands with feet)
Sensation?
Level of Consciousness (LOC)
motor function
pupillary response
vital signs
Glasgow Coma Scale
Neuro checks
A change in LOC is the single most important factor in this examination
Level of Consciousness (LOC)
Check voluntary responses by giving simple commands as this will also help to validate LOC
motor function
Note size and symmetry of both pupils
pupillary response
to establish baseline
vital signs
Accurate and reliable quantitative tool to assess LOC
Glasgow Coma Scale
Upper extremities
Flexion of arm, wrist, and fingers
Adduction of arm: tight against thorax
Lower extremities
Extension, internal rotation, plantar flexion; indicates hemispheric lesion of cerebral cortex
indicates hemispheric lesion of cerebral cortex
Decorticate rigidity
Upper extremities: stiffly extended, adducted, internal rotation, palms pronated
Lower extremities: stiffly extended, plantar flexion; teeth clenched; hyperextended back
More ominous than decorticate rigidity; indicates lesion in brain stem at midbrain or upper pons
Decerebrate rigidity
Decreased or loss of motor function due to problem with motor nerve or muscle fibers
paralysis
sudden twitches, movements, or sounds that people do repeatedly
tics
characterized by sudden, rapid, jerky, purposeless movements that involve the limbs, trunk, or face
occurs at irregular intervals, and the movements are all accentuated by voluntary actions.
chorea
involuntary contraction of opposing muscle groups resulting in rhythmic movement of one or more joints.
tremors
drooping of eyes
ptosis
creates involuntary muscle contractions
clonus
diminished or absent superficial reflexes, and increased muscle tone or spasticity can be expected with upper motor neuron lesions
hyperreflexia
associated w/ herniated intervertebral disk or lower motor neuron lesions
hyporeflexia
abnormal sensation (burning, tingling, numbness, prickling, crawling skin sensation).
paresthesia
