neurological system Flashcards
what is CSF and what is contained in it?
is a colorless, odorless fluid containing
- glucose, electrolytes, oxygen, water, carbon dioxide, and leukocytes
where does csf circulate
circulates around the brain and spinal cord
what does csf provide?
provides cushion, maintains normal intracranial pressure, nutrition, and removes metabolic wastes
what does the nervous system control
controls body function through voluntary and autonomic response to external and internal stimuli
structural divisions of the nervous system are:
- central nervous system (CNS), which consists of the brain and spinal cord
- peripheral nervous system (what you feel)
- autonomic nervous system (flight/fight)
what does the skull protect
protects brain
what is the foramen magnum
large oval opening at base of skull
3 layers of meninges
- dura mater: outer double layer
- arachnoid: middle menigeal layer
- pia matter: inner meningeal layer
what can a neurological screening evaluate
major indicators of neurological funcation and assist with recognition of areas of dysfunction
examination components
- mental staus examination to test brain function
- assessment of cranial nerve actions
- motor function to test cerebellar function
- sensory function
- reflexes
equipment
- snellen and rosenbaum eye chart s
- aromatic substacnes
- tongue blades
- penlight
- tuning fork
- relfex hammer
intracranial regulation
mechanisms that facilitate or impair neurologic function
interrrelationships
- brain requires oxygenation
- respiratory and cardiovascular systems impacted by neurological control
extensions of neurological function
- sensory perception
- tactile perception
alert
client is responsive and able to open eyes and answer questions spontaneously and appropriately
lethargic
the client is able to open their eyes and respond but is drowsy and falls alseep readily
obtunded
client responds to light shaking but can be confused and slow to respond
stuporous
client requires painful stimuli (pinching a tendon or rubbing the sternum) to achieve a brief response
comatose
there is no response to repeated painful stimuli
decorticate rigidity
flexion and internal rotation of upper extremity joints and legs
- flex toward body involuntary in clients who are comatose
decerebrate rigidity
neck and elbow extension, with the wrists and fingers flexed
- flew out involuntary
inspecting
- assess apperance by observing hygiene, grooming, and clothing choice
- consider cultural preferences
- assess mood by inspecting mannerism and actions during interactions
expected findings for insepction
client makes eye contact and emotions correspond to the conversation and situation
memory
both recent and remote
how do you test recent knowledge?
ask the client to repeat a series of numbers
how to test remote knowledge
ask the client to state their birth date or mother’s maiden name (verifiable)
how to test someone’s level of knowledge
ask the client what they know about their current hospitalization or illness
how to assess the ability for calculation
ask the client to count backwrd from 100 by 7s
how to assess abstract thinking
ask the client the interpreation of a cliche (“cat got you r tongue”)
- demonstrates higher level of thought processes
how to assess insight
perform an objective assessment of the clients perception of illness
how to assess judgment
ask client about the soltuion to a specific dilemma
how to assess the thought process
note processing differences (rapid change of topic) and use of nonsense words
thought content
note the presence of delusions, hallucinations, and other ideas the client presents during the interview
what should be expected of speech
speech and language and features (quality, quantity, and volume to be articulate and responses to be meaningful and appropriate
standardized screening tools
use the mini-mental state examination to assess cognitive status objectively
evaluates
- orientation to time and place
- attention and calculation of counting backward by sevens
- registatring and recalling objects
- language, including naming of objects, following of commands
time, place, person
ask if orientation is a concern during history
date and time
first orientation to disappear
- only a problem if remains disoriented after being reoriented
place
second orientation to disappear
person
last orientation to disappear
orientation returns in what order
opposite in which it is lost
glasgow coma scale
obtain a baseline assessment of the cleints leevl of consciousness and for ongoing assessment
what does the glasgow coma scale look at
eye, verbal, and motor response, and assigns a number values based on the clients response
- highest level 15 (awake & full consciousness)
altered level of consciousness (LOC)
nurse can determine if the pt. is alert and oriented by the way questions are answered during interview
what does change in loc show
earliest and most sensitive idicator of alterations in cerebral function
what is wakefullness controlled by
brainstem
what is the awareness - higher level function controlled by
reticular activating system
test cerebral function for….
balance and coordination
tests for balance
- romberg test
- stand on one foot
- tandem walking
- hopping on one foot
knee bending
motor function
assess coordination by asking the client to extend the arms and rapidly touch one finger to the nose, alternating hands, and than doing it with eyes closed
expected findings of motor function
smooth, coordinated movement
- assess gain when client is awake and unaware
- gait is steady, smooth and coordinated
romberg test
(pt. standing)- feet together, arms at side eyes open/closed. client should stand with minimal swaying
heel to toe walk
walk heel to toe
how do you assess muscle strength
assess the strength of muscle groups by asking the client to push or pull against resistance
- strength would be equal or slightly stronger on the dominant side of the body
when preformign sensory function you should preform test on….
al four extremities
how can you assess pain sensation
alterating sharp and dull objects on the skin and asking the client to report what they feel
assessing vibration
have client report when and where tehy feel the handle of the vibrating tunning fork on their skin
two point discrimination
open paperclips to determine the smallest distance between the two points at which client can still feel the two points on skin and not just one
stereognosis
place afamilar object in clients hand and ask them to identify it
graphesthesia
trace a number on the clients palm with the blunt end of a pencil and ask them to identify it
how are reflexes tested
observing muscle movement in response to sensory stimuli
deep tendon reflexes
responses to stimulation of tendon that streches neuromuscular spindles of muscle group
what happens when you strike a deep tendon
stimulates a sensory neuron that travels to spinal cord where it stimulates an interneuron, which stimulates a motor neuron to create movement
deep tendon grade/ documentation
4+= very brisk with clonus (normal) 3+= more brisk than average 2+= expected 1+= diminished 0+= no response
findings with aging
short term mem declin e
diminished reflex and reaction times
altered vibration, position, hearing, vision, smell, and deep pain
slower fine finger movement
increased difficulty learning complex or abstract data
fewer brain cells, smaller brain volume, deteriorating nerve cells, fever neurotransmitter
impaired balance
decreased touch sensation
assessing neuro system in older adults
follows same procedure as younger adults
- test for balance and gait are often assessed for older adults to identify those at risk for falls
brain stems
- pons relays impulses to brain centers and lower spinal nerves
how many cranial nerves are there
12
how many motor fibers
5
how mnay sensory
3
how many motor and sensory
4
disorders of neuro
meningitis encephalitis multiple sclerosis parkinsons disease seizures headaches
kernigs sign
flexing one leg than extending knee
- no pain
brudzinskis
flexes hip and knee in response to head flexion
spinal cord injury
any tramatic disruption of spinal cord
- veterbral fractures, dislocations, cars, sport injurys
complete spinal cord injury to cervical spinal cord
quadriplegia
aleheimers
incurable, degeneraive neurologic disorder, begins with decline in memory
cerebrovascular accident (CVA, stroke)
when cerebral blood vessels become occluded by thrombys or embolus, or when intracranial hemorrhage occurs, brain tissue become ischemic, resulting in CVA or stroke
aphasia/dysphasia
trouble communicating
