Chapter 26 Neurological
Terms in this set (29)
What does the brain do under unconscious control?
respiration, temperature regulation, and movement coordination
What is the goal of a neurological assessment?
∙ detect a change in neurological status, particularly acute or life-threatening
∙ make a medical diagnosis
What do nurses perform neurological assessments for?
to detect actual or potential health problems related to neurological dysfunction and the patients' response to those problems
If a patient says "this is the worst headache of my life", what do you do?
it is an emergency referral screening for a possible stroke
What is a concussion?
direct blow that causes the brain to shift rapidly back and forth in the skull
What is syncope?
sudden loss of strength, a temporary loss of consciousness from lack of cerebral blood flow- fainting
What is a tremor?
involuntary shaking, vibrating, or trembling
What is paresis and paralysis?
∙ partial or incomplete paralysis
∙ loss of motor function caused by a lesion in the neurologic or muscular system or loss of sensory innervation
What is dysmetria?
inability to control power, speed, or distance of a muscular action
What is paresthesia?
What is a screening neurological examination?
done on seemingly well people who have no significant subjective finding from their history
What is a complete neurologic examination?
done on people who have neurologic concerns
What is a neurologic recheck?
done on people who have neurologic deficits who require periodic checks
What is the sequence for complete neurologic examination?
1. mental status- LOC, alertness
2. cranial nerves
3. motor system- strength
4. sensory system- pain, touch
5. reflexes- DTR
List the cranial nerves.
CN I: Olfactory: smell
CN II: Optic: sight
CN III: Oculomotor: pupils, eyelids
CN IV: Trochlear: eye movements
CN V: Trigeminal: head and face, chewing, swallowing, movements, muscle sense
CN VI: Abducens: eye movement left to right
CN VII: Facial: facial movements
CN: VIII: Acoustic (vestibulocochlear): hearing, balance
CN: IX: Glossopharyngeal: tongue, swallowing
CN: X: Vagus: speech, swallowing
CN: XI: Spinal accessory: shoulders and head movement
CN: XII: Hypoglossal: tongue movement
What test is done on optic nerve?
visual acuity and confrontation
What test is done on the facial nerve?
smile, frown, raise eyebrows, close eyes tightly, show teeth, puff cheeks, poke air out
What test is done on the glossopharyngeal and vagus nerve?
"ahhhhh" with tongue blade and gag reflex
Hoe do you test the spinal accessory nerve?
push down on shoulders as they push vise versa, turn their head as they push and vise versa
Describe examining and testing the muscles.
∙ Size: compare each muscle, should be bilateral
∙ Strength: test the power of each muscle simultaneously
∙ Tone: normal degree of tension in voluntarily relaxed muscles
∙ Involuntary movements: tic, tremors
Describe the balance test.
∙ Gait: ask them to walk at end of examination tandem walking and regular
∙ Romberg test: close eyes and stand straight up; also knee up balancing
Describe the coordination and skilled movement test.
∙ Rapid alternating movements: patient needs to pat the knees with both hands fast
∙ Finger-to-finger test: fast
∙ Finger-to-nose test: close their eyes and stretch out arms
∙ Heel-to-shin test: move heel straight down shin
Describe the sensory tests.
∙ Pain: broken tongue blade
∙ Light touch: cotton ball
∙ Vibration: tuning fork over bony prominences
∙ Position (Kinesthesia): patients ability to perceive passive movement
∙ Tactile discrimination: Stereognosis- patients ability to recognize familiar objects by touch, Graphesthesia- read number traced on skin
∙ Two-point discrimination: ability to point out two stimuli on the skin
∙ Extinction: touch body parts on same side
∙ Point location: touching them then them putting their finger where you touched
Describe testing the deep tendon reflexes.
position it, technique when striking, grading it
4+ very brisk, hyperactive with clonus, indicates disease
3+ brisker than average, may indicate disease, probably normal
2+ average, normal
1+ diminishes, low normal, occurs only with reinforcement
0 no response
Review Glasgow coma scale.
normal score= 15
score of 7 or less= coma
Describe the acute assessment.
∙ significant changes in mental status
∙ changes not explained
∙ seizure activity possible
∙ onset flexor or extensor posture
∙ change in size and decreased reactivity to light in one or both pupils
∙ onset of eye deviation
∙ progressing weakness
∙ changes in ability to sense
∙ significant changes in VS
Describe the abbreviated acute assessment.
∙ rapid assessment of LOC and Glasgow coma scale
∙ pupil reaction
∙ assess extremity strength
∙ assess sensation
What are some infant lifestyle considerations?
∙ rooting reflex
∙ palmar grasp
∙ Babinski reflex: toes should fan younger than 2 years of age, after that, they should curl
∙ tonic neck reflex
∙ Moro reflex: scaring them
What are some aging adult considerations?
∙ decreased muscle bulk
∙ senile tremors
∙ slower gait
∙ decreased DTRs
∙ plantar reflex absent or difficult to interpret