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Health assessment units 4 and 5 > Nervous System > Flashcards

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

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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

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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

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4
Q

0-17 severe impairment, 18-23 mild impairment, 27 is normal

A

MMSE

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5
Q
  • alert
  • lethargic (somnolent)
  • obtunded
  • stupor (semi-coma)
  • coma
  • delirium
  • dementia
A

Level of Consciousness (LOC) terms

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6
Q

Awake or easily aroused. Fully aware of surroundings. Appropriate responses.

A

Alert

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7
Q

drifts to sleep when not stimulated

A

Lethargic (somnolent)

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8
Q

Difficult to arouse, confusion when aroused, requires constant stimuli

A

obtunded

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9
Q

Spontaneous unconscious, Responds to painful stimuli, Non-verbal response to pain

A

stupor (semi-coma)

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10
Q

Unconscious, no response to stimuli

A

coma

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11
Q

Inattentive, incoherent, impaired recent memory

A

delirium

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12
Q

Loss of cognitive and intellectual function. Consciousness intact. Impaired judgement, disorientation, memory loss.

A

dementia

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13
Q

Oriented to person, place, time, and situation

A
  • what is your name?
  • do you know where you are?
  • what month is it?
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14
Q

Levels of arousal

A
  • verbal stimuli
  • tactile stimuli
  • painful stimuli
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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

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16
Q

Alert, appropriate facial expression and fluent, understandable speech. Affect and verbal response are appropriate.

A

Documentation for normal mental status: Behavior

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17
Q

Oriented to person and place. Cooperative. Recent and Remote memory intact.

A

Documentation for normal mental status: cognition

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18
Q

Thought process logical and coherent. No suicidal ideation. MMSE score 28.

A

Documentation for normal mental status: thought process

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19
Q

equipment for physical assessment

A
  • penlight
  • tongue blade
  • cotton swab
  • tuning fork
  • percussion hammer
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20
Q

cranial nerves III, IV, VI, XI, XII

A

motor cranial nerves

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21
Q

cranial nerves I, II, VIII

A

sensory cranial nerves

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22
Q

cranial nerves V, VII, IX, X

A

motor and sensory (mixed) cranial nerves

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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)

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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)

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25
Q

EOM, pupil constriction

Eye movement through 6 visual fields of gaze, opening of eyelids, pupil constriction, and lens shape
PERRLA
Ptosis

A

cranial nerve III (oculomotor)

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26
Q

EOM

Downward and inward movement of the eyes
Strabismus

A

cranial nerve IV (trochlear)

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27
Q

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

A

cranial nerve V (trigeminal)

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28
Q

EOM

Lateral movement of eyes
Nystagmus is back-&-forth oscillation of eyes

A

cranial nerve VI (abducens)

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29
Q

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

A

cranial nerve VII (facial)

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30
Q

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

A

cranial nerve VIII (auditory)

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31
Q

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)

A

cranial nerve IX (glossopharyngeal)

32
Q

Sensation of pharynx & larynx; motor activity of swallowing & vocal cords; sensory in cardiac, respiratory, & blood pressure reflexes; peristalsis; digestive secretions

A

cranial nerve X (vagus)

33
Q

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

A

cranial nerve XI (spinal accessory)

34
Q

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

A

cranial nerve XII (hypoglossal)

35
Q
  • muscle tone
  • motor function
  • balance and gait
  • sensation
  • reflexes
A

further assessment

36
Q

ensure to inspect for size for all muscle groups. compare right size to left size.

assess for atrophy and assess for ROM

A

muscle tone

37
Q

Rapid Alternating Movements (RAM)

Finger-Nose-Finger

Heel-to-Shin

A

motor function

38
Q

test for ataxia

Romberg’s test

A

Gait and balance

39
Q

assessment of proprioception

positive test = loss of balance
ataxia is sensory in nature

A

Romberg’s test

40
Q
  • stereognosis
  • graphesthesia
  • point localization
  • sensory extinction
A

Sensation

41
Q

Place a familiar object in the palm of the client’s hand and have them identify it.

A

Stereognosis

42
Q

assess by drawing a number or letter in the palm of a client’s hand and having the client identify what was drawn.

A

Graphesthesia

43
Q

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.

A

point localization

44
Q

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.

A

sensory extinction

45
Q

response is graded on 4-point scale:

4
3
2
1
0

A

reflexes

46
Q

very brisk, hyperactive with clonus, indicative of disease

A

4

47
Q

brisker than average, may indicate disease

A

3

48
Q

Average, normal

A

2

49
Q

diminished, low normal, or occurs with reinforcement

A

1

50
Q

no response

A

0

51
Q
  • biceps reflex, C5 to C6
  • brachioradialis reflex, C5 to C6
  • triceps reflex, C7 to C8
A

DTR - arm

52
Q

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

A

Biceps reflex, C5 to C6

53
Q

Normal response is flexion and supination of forearm

A

Brachioradialis reflex, C5 to C6

54
Q

Tell person to let arm “just go dead” as you strike triceps tendon directly just above the elbow
Normal response is extension of forearm

A

Triceps reflex, C7 to C8

55
Q
  • quadriceps reflex, L2 to L4
  • Achilles reflex, L5 to S2
  • Babinski
A

DTR - leg

56
Q

Let lower legs dangle freely to flex knee and stretch tendons; strike tendon directly just below patella
Normal response is extension of lower leg

A

Quadriceps reflex, L2 to L4

57
Q

Position person with knee flexed; hold foot in dorsiflexion and strike Achilles tendon directly
Normal response is foot plantar flexes against your hand

A

Achilles reflex, L5 to S2

58
Q

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

A

Babinski

59
Q

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

A

clonus

60
Q

sucking
rooting
tonic neck (fencing)
Step reflex
palmer
plantar
crawl reflex
moro reflex

A

reflexes - infant

61
Q

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

A

Neuro checks

62
Q

A change in LOC is the single most important factor in this examination

A

Level of Consciousness (LOC)

63
Q

Check voluntary responses by giving simple commands as this will also help to validate LOC

A

motor function

64
Q

Note size and symmetry of both pupils

A

pupillary response

65
Q

to establish baseline

A

vital signs

66
Q

Accurate and reliable quantitative tool to assess LOC

A

Glasgow Coma Scale

67
Q

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

A

Decorticate rigidity

68
Q

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

A

Decerebrate rigidity

69
Q

Decreased or loss of motor function due to problem with motor nerve or muscle fibers

A

paralysis

70
Q

sudden twitches, movements, or sounds that people do repeatedly

A

tics

71
Q

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.

A

chorea

72
Q

involuntary contraction of opposing muscle groups resulting in rhythmic movement of one or more joints.

A

tremors

73
Q

drooping of eyes

A

ptosis

74
Q

creates involuntary muscle contractions

A

clonus

75
Q

diminished or absent superficial reflexes, and increased muscle tone or spasticity can be expected with upper motor neuron lesions

A

hyperreflexia

76
Q

associated w/ herniated intervertebral disk or lower motor neuron lesions

A

hyporeflexia

77
Q

abnormal sensation (burning, tingling, numbness, prickling, crawling skin sensation).

A

paresthesia

Health assessment units 4 and 5 (3 decks)

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