Nervous System Flashcards
1
Q
- Headache
- Head Injury
- Dizziness
- Seizures
- Tremors
- Weakness
- Coordination
- Numbness or tingling
- Difficulty swallowing
- Older Adult = Changes in vision, memory or confusion
A
subjective data
2
Q
- mental status
- cranial nerves
- motor and sensory systems
- reflexes
should be performed on anyone w/ neurologic concerns
recheck anyone w/ deficits
A
neurologic exam
3
Q
- 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)
A
Mental status
4
Q
0-17 severe impairment, 18-23 mild impairment, 27 is normal
A
MMSE
5
Q
- alert
- lethargic (somnolent)
- obtunded
- stupor (semi-coma)
- coma
- delirium
- dementia
A
Level of Consciousness (LOC) terms
6
Q
Awake or easily aroused. Fully aware of surroundings. Appropriate responses.
A
Alert
7
Q
drifts to sleep when not stimulated
A
Lethargic (somnolent)
8
Q
Difficult to arouse, confusion when aroused, requires constant stimuli
A
obtunded
9
Q
Spontaneous unconscious, Responds to painful stimuli, Non-verbal response to pain
A
stupor (semi-coma)
10
Q
Unconscious, no response to stimuli
A
coma
11
Q
Inattentive, incoherent, impaired recent memory
A
delirium
12
Q
Loss of cognitive and intellectual function. Consciousness intact. Impaired judgement, disorientation, memory loss.
A
dementia
13
Q
Oriented to person, place, time, and situation
A
- what is your name?
- do you know where you are?
- what month is it?
14
Q
Levels of arousal
A
- verbal stimuli
- tactile stimuli
- painful stimuli
15
Q
Sitting erect with no involuntary body movements. Dress and grooming are appropriate for season and setting.
A
Documentation for normal mental status: Appearance
16
Q
Alert, appropriate facial expression and fluent, understandable speech. Affect and verbal response are appropriate.
A
Documentation for normal mental status: Behavior
17
Q
Oriented to person and place. Cooperative. Recent and Remote memory intact.
A
Documentation for normal mental status: cognition
18
Q
Thought process logical and coherent. No suicidal ideation. MMSE score 28.
A
Documentation for normal mental status: thought process
19
Q
equipment for physical assessment
A
- penlight
- tongue blade
- cotton swab
- tuning fork
- percussion hammer
20
Q
cranial nerves III, IV, VI, XI, XII
A
motor cranial nerves
21
Q
cranial nerves I, II, VIII
A
sensory cranial nerves
22
Q
cranial nerves V, VII, IX, X
A
motor and sensory (mixed) cranial nerves
23
Q
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
A
Cranial nerve I (olfactory)
24
Q
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
A
Cranial nerve II (optic)
25
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)
26
EOM
Downward and inward movement of the eyes
Strabismus
cranial nerve IV (trochlear)
27
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)
28
EOM
Lateral movement of eyes
Nystagmus is back-&-forth oscillation of eyes
cranial nerve VI (abducens)
29
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)
30
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)
31
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)
32
Sensation of pharynx & larynx; motor activity of swallowing & vocal cords; sensory in cardiac, respiratory, & blood pressure reflexes; peristalsis; digestive secretions
cranial nerve X (vagus)
33
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)
34
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)
35
- muscle tone
- motor function
- balance and gait
- sensation
- reflexes
further assessment
36
ensure to inspect for size for all muscle groups. compare right size to left size.
assess for atrophy and assess for ROM
muscle tone
37
Rapid Alternating Movements (RAM)
Finger-Nose-Finger
Heel-to-Shin
motor function
38
test for ataxia
Romberg's test
Gait and balance
39
assessment of proprioception
positive test = loss of balance
ataxia is sensory in nature
Romberg's test
40
- stereognosis
- graphesthesia
- point localization
- sensory extinction
Sensation
41
Place a familiar object in the palm of the client’s hand and have them identify it.
Stereognosis
42
assess by drawing a number or letter in the palm of a client’s hand and having the client identify what was drawn.
Graphesthesia
43
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
44
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
45
response is graded on 4-point scale:
4
3
2
1
0
reflexes
46
very brisk, hyperactive with clonus, indicative of disease
4
47
brisker than average, may indicate disease
3
48
Average, normal
2
49
diminished, low normal, or occurs with reinforcement
1
50
no response
0
51
- biceps reflex, C5 to C6
- brachioradialis reflex, C5 to C6
- triceps reflex, C7 to C8
DTR - arm
52
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
53
Normal response is flexion and supination of forearm
Brachioradialis reflex, C5 to C6
54
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
55
- quadriceps reflex, L2 to L4
- Achilles reflex, L5 to S2
- Babinski
DTR - leg
56
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
57
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
58
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
59
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
60
sucking
rooting
tonic neck (fencing)
Step reflex
palmer
plantar
crawl reflex
moro reflex
reflexes - infant
61
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
62
A change in LOC is the single most important factor in this examination
Level of Consciousness (LOC)
63
Check voluntary responses by giving simple commands as this will also help to validate LOC
motor function
64
Note size and symmetry of both pupils
pupillary response
65
to establish baseline
vital signs
66
Accurate and reliable quantitative tool to assess LOC
Glasgow Coma Scale
67
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
68
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
69
Decreased or loss of motor function due to problem with motor nerve or muscle fibers
paralysis
70
sudden twitches, movements, or sounds that people do repeatedly
tics
71
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
72
involuntary contraction of opposing muscle groups resulting in rhythmic movement of one or more joints.
tremors
73
drooping of eyes
ptosis
74
creates involuntary muscle contractions
clonus
75
diminished or absent superficial reflexes, and increased muscle tone or spasticity can be expected with upper motor neuron lesions
hyperreflexia
76
associated w/ herniated intervertebral disk or lower motor neuron lesions
hyporeflexia
77
abnormal sensation (burning, tingling, numbness, prickling, crawling skin sensation).
paresthesia
