MS CH 47 Neurologic System Function, Assessment, and Therapeutic Measures PDF

4068_Ch47_1095-1117 15/11/14 2:12 PM Page 1096 47 Neurologic System Function, Assessment, and Therapeutic Measures KEY TERMS...

4068_Ch47_1095-1117 15/11/14 2:12 PM Page 1096 47 Neurologic System Function, Assessment, and Therapeutic Measures KEY TERMS DEBORAH L. WEAVER anisocoria (an-ih-suh-KOR-ee-ah) AND JANICE L. BRADFORD aphasia (ah-FAY-zee-ah) cerebrovascular (sur-EE-broh-VASS-kyoo-lur) contractures (kon-TRAK-churs) LEARNING OUTCOMES decerebrate (dee-SER-eh-brayt) decorticate (dee-KOR-tih-kayt) 1. Describe the normal structures and functions of the nervous dysarthria (diss-AR-three-ah) system dysphagia (diss-FAYJ-ee-ah) 2. Identify the effects of aging on the nervous system. electroencephalogram (ee-LEK-troh-en-SEFF-uh-loh- gram) 3. List data to collect when caring for a patient with a disorder myelogram (MY-eh-loh-gram) of the nervous system. nystagmus (nih-STAG-mus) paresis (puh-REE-sis) 4. Identify tests used to diagnose disorders of the nervous paresthesia (PAR-es-THEE-zee-ah) system. subarachnoid (SUB-uh-RAK-noyd) 5. Plan nursing care for patients undergoing each of the diagnostic tests for disorders of the nervous system. 6. Describe common therapeutic measures that are used for patients with disorders of the nervous system. 1096 4068_Ch47_1095-1117 15/11/14 2:12 PM Page 1097 Chapter 47 Neurologic System Function, Assessment, and Therapeutic Measures 1097 NORMAL NEUROLOGIC SYSTEM (efferent), or an interneuron (between the afferent and efferent ANATOMY AND PHYSIOLOGY neurons, Fig. 47.2). Receptors are specialized to detect external or internal changes and then generate electrical impulses. The nervous system has tw o divisions: the central nerv ous Sensory neurons, from receptors in the skin, skeletal muscles, system (CNS), which consists of the brain and spinal cord, and and joints, are called somatic. Those sensory neurons from the peripheral nervous system (PNS), which includes the nerves receptors in internal organs are called visceral sensory neurons. of the autonomic nervous system (ANS). Electrical impulses Motor neurons that innerv ate skeletal muscle are called are transmitted through the nervous system to permit sensory, somatic; those to smooth muscle, cardiac muscle, and glands motor, and integrative activity. Actions are either automatic by are called visceral. reflex or a result of gathering, organizing, and processing data. Nerve Tissue Nerve tissue consists of neurons and support cells called LEARNING TIP neuroglia (Table 47.1). There is diversity in neurons; including To remember the difference between afferent and unipolar, bipolar, and multipolar anatomy. Most common is efferent, try these clues: the multipolar neuron with multiple dendrites and a singular axon (Fig. 47.1). Afferent: A is for affect or sense. Myelination of axons increases their conduction speed. Efferent: E is for effect (action). The level of myelination correlates to the necessity of speed. Or, think of the alphabet—A before E: You For example, neurons in volved in protecti ve reflexes are have to feel or sense (afferent) a stimulus heavily myelinated, whereas processing neurons of the CNS before you can take action (efferent). lack myelin. Types of Neurons Functional classification of neurons considers their position Nerve Impulses and direction of signal: a neuron is sensory (af ferent), motor A nerve impulse, which is also called an action potential, is an electrical change brought about by the movement of ions across the neuron cell membrane. When a neuron is at rest, it is polarized with a positive charge outside the membrane and a relatively negative charge inside the membrane. A threshold TABLE 47.1 NEUROGLIA OF THE CNS stimulus will cause a reversal in charge (action potential). A wave of depolarization travels the length of the neuron as a Name Function positive feedback loop. Immediately after is repolarization, Oligodendrocytes Produce the myelin sheath to restoring the positive charge outside and the negative charge electrically insulate neurons of inside. After a refractory period (the brief time after being the central nervous system. stimulated when a nerve still can’t react to another stimulus), Microglia Capable of movement and the neuron is polarized again and ready to respond to another phagocytosis of pathogens stimulus. A myelinated neuron is capable of transmitting and damaged tissue. hundreds of impulses per second and at speeds of more than 100 meters per second. Astrocytes Contribute to the blood–brain barrier, which prevents poten- Synapses tially toxic waste products in Neurons typically work in a circuit. When the axon of a the blood from diffusing out neuron must transmit an impulse to the dendrite or cell body into brain tissue. of another neuron, the impulse must cross a small gap called Disadvantage: Some useful a synapse. An electrical impulse is incapable of crossing this medications cannot cross the microscopic space, so when an impulse reaches the synapse, blood–brain barrier, which impulse transmission becomes chemical. becomes important during At chemical synapses, impulse transmission is one w ay brain infection, inflammation, because the neurotransmitter is released only by the presynaptic or other disease. neuron; the impulse cannot go backward. This is important for Ependyma Line the ventricles of the the normal activity of functional neurons. The relative complex- brain. ity of synapses also makes them a potential target for the actions Many of the cells are ciliated. of medications. For example, some antidepressants block the Involved in production and cir- reuptake (reabsorption) of serotonin, a neurotransmitter , back culation of cerebrospinal fluid. into the proximal nerve endings, increasing the mood-elevating serotonin levels in the synapse. 4068_Ch47_1095-1117 15/11/14 2:12 PM Page 1098 1098 UNIT THIRTEEN Understanding the Neurologic System The cell body (also called the soma) is the control center of the neuron and contains the nucleus. Dendrites, which look like the bare branches of a tree, receive signals from other neurons and conduct the information to the cell body. Some neurons have only one dendrite; others have Nucleus thousands. The axon, which carries nerve signals away from the body, is longer than the dendrites and contains few branches. Nerve cells have only one axon; however, the length of the fiber can range from a few millimeters to as much as a meter. The axons of many (but not all) neurons are encased in a myelin sheath. Consisting mostly of lipid, myelin acts to insulate the axon. In the peripheral nervous system, Schwann cells form the myelin sheath. In the CNS, oligodendrocytes assume this role. Gaps in the myelin sheath, called nodes of Ranvier, occur at evenly spaced intervals. The end of the axon branches extensively, with each axon terminal ending in a synaptic knob. Within the synaptic knobs are vesicles containing a neurotransmitter. FIGURE 47.1 Multipolar neuron structure. From Thompson, G. S. (2013). Understanding anatomy and physiology. Philadelphia: F.A. Davis, p. 157. Interneurons Interneurons, which are found only in the CNS, connect the incoming sensory pathways with the outgoing motor Sensory neurons pathways. Besides receiving, processing, Motor neurons and storing information, the connections Sensory (afferent) neurons Motor (efferent) neurons made by these neurons make each of us detect stimuli—such as touch, relay messages from the unique in how we think, feel, and act. pressure, heat, cold, or brain (which the brain emits chemicals—and then transmit in response to stimuli) to the information about the stimuli muscle or gland cells. to the CNS. FIGURE 47.2 Neurons: sensory, interneurons, motor. From Thompson, G. S. (2013). Understanding anatomy and physiology. Philadelphia: F.A. Davis, p. 156. 4068_Ch47_1095-1117 15/11/14 2:12 PM Page 1099 Chapter 47 Neurologic System Function, Assessment, and Therapeutic Measures 1099 Nerves and Nerve Tracts Spinal Cord Reflexes A nerve (whether cranial, spinal, or peripheral) is a group of A reflex is a fast, involuntary, automatic, and predictable re- axons with blood vessels, wrapped in connective tissue. Most sponse to a stimulus. A spinal cord reflex uses a neural circuit, nerves are mixed; that is, they contain both sensory and motor independent of the brain, called a spinal refle x arc. Sensory neurons. Some, however, are not mix ed. For example, the input elicits motor output (Fig. 47.5). optic nerve for vision is sensory only; and the autonomic The somatic spinal cord reflexes include stretch reflexes and nerves are purely motor. flexor reflexes. In a stretch refle x, a muscle that is stretched A nerve tract is a group of thickly myelinated neurons automatically contracts; an e xample is the f amiliar patellar within the CNS; such tracts within white matter appear white reflex, but all skeletal muscles have such a refle x. Because due to the myelin sheaths. A nerve tract within the spinal cord gravity exerts a constant force on the body, the purpose of these carries either sensory or motor impulses; those within the reflexes is to keep the body upright without requiring conscious brain may have sensory, motor, or integrative functions. processing. They also avoid potential injury from overstretching a muscle. Fle xor reflexes may also be called withdra wal Spinal Cord reflexes: the stimulus is painful trauma to tissue and the The spinal cord transmits impulses to and from the brain and response is to pull away from it. Again, this occurs without the is the integrating center for spinal cord refle xes. The spinal need for conscious thought; the brain is not directly involved. cord is within the vertebral canal formed by the vertebrae of The clinical testing of spinal cord reflexes provides a way the skeleton and extends from the foramen magnum of the to assess the functioning of their reflex arcs. For example, if occipital bone to the intervertebral disk between the first and the patellar refle x is absent, the problem might be in the second lumbar vertebrae. The spinal nerves emerge from the quadriceps femoris muscle, the femoral nerv e, or the spinal intervertebral foramina. cord itself. If the reflex is present, it indicates that all parts of In cross-section, the spinal cord is oval shaped; internally it the reflex arc are functioning normally. has an H-shaped mass of gray matter surrounded by white matter (Fig. 47.3). Each spinal nerve attaches to the cord by two Brain roots: dorsal and ventral. Meninges (three concentric, external The brain consists of many parts that function as an integrated layers of connective tissue) and circulating cerebrospinal fluid whole. The four principle areas are the cerebrum, the (CSF) offer further protection to the spinal cord. diencephalon (thalamus and hypothalamus), the brainstem (midbrain, pons, and medulla oblongata), and the cerebellum Spinal Nerves (Fig. 47.6). There are 31 pairs of spinal nerv es, named according to their respective vertebrae: 8 cervical pairs, 12 thoracic pairs, 5 lumbar Meninges pairs, 5 sacral pairs, and 1 coccygeal pair. These nerves are often The meninges are the three layers of connecti ve tissue that referred to by letter and number: the second cervical nerv e is cover the CNS. Where they enclose the brain, they are referred C2, the tenth thoracic is T10, and so on (Fig. 47.4). to as cranial meninges. CSF circulates in the subarachnoid space. A small space—called the epidural space—lies between the outer covering of the spinal cord and White matter the vertebrae; it contains a cushioning layer of fat appears white as well as blood vessels and connective tissue. because of its Posterior horn abundance of Anterior horn myelin. It contains bundles of axons (called Spinal nerve tracts) that carry impulses from one part of the nervous system The central canal carries to another. cerebrospinal fluid through the spinal cord. Vertebral body Gray matter—which appears gray because of its lack of myelin—contains mostly the cell bodies of motor neurons and interneurons. This H-shaped mass is divided into two sets of horns: the posterior (dorsal) horns and the ventral (anterior) horns. FIGURE 47.3 Spinal cord—internal anatomy, cross-section, superior view. From Thompson, G. S. (2013). Understanding anatomy and physiology. Philadelphia: F.A. Davis, p. 165. 4068_Ch47_1095-1117 15/11/14 2:12 PM Page 1100 1100 UNIT THIRTEEN Understanding the Neurologic System Nerves from the cervical region of the spinal cord innervate the chest, head, neck, shoulders, arms, hands, and diaphragm. Basically a bundle of nerve fibers, the spinal cord extends from the base of the Nerves from the thoracic brain until about the region extend to the first lumbar vertebra. intercostal muscles of the ribcage, the abdominal muscles, and the back muscles. The lumbar spinal nerves innervate the lower abdominal wall Extending from the and parts of the thighs end of the spinal cord and legs. is a bundle of nerve roots called the cauda equina— so named because it Nerves from the sacral look like a horse’s tail. region extend to the thighs, buttocks, skin of the legs and feet, and anal and genital regions. FIGURE 47.4 Spinal cord—full length, posterior view. From Thompson, G. S. (2013). Understanding anatomy and physiology. Philadelphia: F.A. Davis, p. 164. 2 Afferent (sensory) nerve fibers send a signal directly to the spinal cord. 3 The impulse immediately passes to a motor neuron. 1 Somatic receptors (located in the skin, a muscle, or a tendon) detect a sensation, such as the stretching of the thigh muscle when the patellar tendon is tapped. 4 The motor neuron initiates an impulse back to the muscle, causing it to contract, producing a slight kick in the lower leg. FIGURE 47.5 Somatic spinal reflex. From Thompson, G. S. (2013). Understanding anatomy and physiology. Philadelphia: F.A. Davis, p. 169. 4068_Ch47_1095-1117 15/11/14 2:12 PM Page 1101 Chapter 47 Neurologic System Function, Assessment, and Therapeutic Measures 1101 Gyri Sulci The cerebrum is the largest portion of the brain. It’s surface is marked by thick ridges called gyri (singular: gyrus). Shallow grooves called sulci (singular: sulcus) divide the gyri. Deep sulci are called fissures. The diencephalon sits between the cerebrum and the midbrain. The cerebellum is the second largest region of the brain. The brainstem makes up the rest of the brain. It consists of three structures: Midbrain Pons Medulla oblongata FIGURE 47.6 General structures of the brain—external, left lateral view. From Thompson, G. S. (2013). Understanding anatomy and physiology. Philadelphia: F.A. Davis, p. 170. Ventricles and Cerebrospinal Fluid receptors in the inner ear to detect mo vement and changes in position. The ventricles are four cavities within the brain: tw o lateral ventricles are located within the cerebral hemispheres, the Diencephalon: Thalamus and Hypothalamus third ventricle lays midline within the thalamus, and the fourth Deep beneath the cerebral hemispheres, the diencephalon ventricle is midline between the brainstem and cerebellum. consists primarily of the thalamus and hypothalamus. Above the Cerebrospinal fluid is formed from capillaries of the choroid brainstem, the thalamus acts as a gate way for nearly e very plexus within, and circulates through the four v entricles. sensation traveling to the cerebral cortex. The thalamus filters Circulation of CSF moves inferiorly within the CNS, into the sensory input, permitting the cerebrum to concentrate on more subarachnoid space, and ultimately superiorly to drain into important sensations with less distraction. The hypothalamus the dural v enous sinuses. Cerebrospinal fluid permits the suspends the pituitary gland from a stalk called the infundibulum; exchanges of nutrients and wastes between the blood and CNS they are anatomically and physiologically connected. neurons. It also acts as a cushion or shock absorber for the CNS. The pressure and constituents of CSF may be deter- Cerebrum mined by means of a lumbar puncture (spinal tap) and may The two cerebral hemispheres form the lar gest part of the be helpful in the diagnosis of diseases such as meningitis. human brain. The right and left hemispheres are connected Brainstem: Midbrain, Pons, and Medulla primarily by the corpus callosum, a band of about 300 million Oblongata nerve fibers. The cerebral cortex is folded e xtensively into convolutions (or gyri) that create more surf ace area for Primarily a reflex center, the midbrain regulates visual reflexes neurons. The deep groo ves between the folds are called (coordinated movement of the eyes), auditory reflexes (turning fissures; shallow grooves are called sulci. The cerebral cortex the ear toward a sound), and righting reflexes that keep the head is divided into lobes, whose functions have been extensively upright and contribute to balance. Within the pons are tw o mapped (Fig. 47.7). respiratory centers that work with those in the medulla to pro- Collectively, the cerebral corte x has areas that enable duce a normal breathing rhythm. The medulla lies just superior learning, memory, and thought. It also helps form our indi- to the spinal cord. It regulates the most vital life functions. vidual personalities with comple x behaviors that require Cerebellum integration of several cerebral and lower brain areas. Deep within the white matter of the cerebral hemispheres The cerebellum is posterior to the brainstem. The functions are masses of gray matter called the basal nuclei (ganglia). of the cerebellum include the involuntary aspects of volun- tary movement: coordination, appropriate direction and endpoint of movements, and the maintenance of posture and WORD BUILDING balance. For the maintenance of balance, the cerebellum subarachnoid: sub—below + arachnoid—middle layer of the uses input from vision, proprioceptors, and equilibrium meninges 4068_Ch47_1095-1117 15/11/14 2:12 PM Page 1102 1102 UNIT THIRTEEN Understanding the Neurologic System Frontal Lobe Central sulcus forms Precentral Central sulcus the posterior border Occipital lobe gyrus Postcentral Contains the motor Contains the areas that generate gyrus visual areas impulses that bring that receive about voluntary and interpret movement sight Each motor area controls movement on the opposite side of the body Parietal lobe Usually prominent in Central sulcus the left hemisphere, forms the Broca’s motor anterior border Lateral speech area controls Receives, sulcus the movements perceives, and involved in speaking interprets the Personality aspects somatic senses include: initiative, and taste emotion, judgment, (gustation) reasoning, conscience Temporal lobe Separated from the parietal lobe by the lateral sulcus Contains sensory areas for hearing and olfaction (smell) Visual recognition Also in the temporal and parietal lobes, usually only on the left side, is Wernicke’s area where comprehension of speech occurs. FIGURE 47.7 Cerebrum—lobes, left lateral view. From Thompson, G. S. (2013). Understanding anatomy and physiology. Philadelphia: F.A. Davis, p. 176. Their functions are concerned with certain subconscious aspects of voluntary movement: regulation of muscle tone, LEARNING TIP inhibiting tremor, and use of accessory mo vements such as arm swinging when walking. The cranial nerves are easier to remember when a mnemonic device is used: Cranial Nerves On Olfactory The 12 pairs of cranial nerv es emerge from the brainstem Old Optic with the exception of pair one, which originates from the Olympus’ Oculomotor temporal lobe and pair tw o from the occipital lobe. Some Towering Trochlear are purely sensory nerves, whereas others are mixed nerves. Top Trigeminal The impulses for sight, smell, hearing, taste, equilibrium, A Abducens and somatic senses of supplied areas are all carried by cra- Finn Facial nial nerves to their respective sensory areas in the brain. Very Vestibulocochlear Other cranial nerves carry motor impulses to muscles of the Graciously Glossopharyngeal face, neck, shoulders, and tongue, or to glands. Cranial Viewed Vagal nerves III, VII, IX, and X contain axons of both the somatic A Accessory and autonomic nervous systems. The functions of all the Hop Hypoglossal cranial nerves are summarized in Table 47.2. Autonomic Nervous System Autonomic nervous system (ANS) motor output pro vides Sympathetic Division dual innervation to effectors, that is, smooth muscle, cardiac The cell bodies of the sympathetic pre ganglionic neurons are muscle, and glands that produce the response (effect). These thoracolumbar (in the thoracic and lumbar se gments of the two divisions (sympathetic and parasympathetic) function in spinal cord, Fig. 47.8). The sympathetic division is dominant in opposition to one other and their activity is integrated by the stressful situations such as fear, anger, anxiety, excitement, and hypothalamus. exercise. The responses prepare the body for physical activity, 4068_Ch47_1095-1117 15/11/14 2:12 PM Page 1103 Chapter 47 Neurologic System Function, Assessment, and Therapeutic Measures 1103 TABLE 47.2 CRANIAL NERVES Number Name Function I Olfactory Sense of smell II Optic Sense of sight III Oculomotor Movement of eyeball Constriction of pupil for bright light or near vision IV Trochlear Movement of eyeball V Trigeminal Sensation in face, scalp, and teeth Contraction of chewing muscles VI Abducens Movement of eyeball VII Facial Sense of taste Contraction of facial muscles Secretion of saliva VIII Vestibulocochlear Sense of hearing Sense of equilibrium IX Glossopharyngeal Sense of taste Secretion of saliva Sensory input for cardiac, respiratory, and blood pressure reflexes Contraction of pharynx X Vagus Sensory input in cardiac, respiratory, and blood pressure reflexes Sensory and motor input to larynx (speaking) Decreased heart rate Contraction of alimentary tube (peristalsis) Increased digestive secretions XI Accessory Contraction of neck and shoulder muscles Motor input to larynx (speaking) XII Hypoglossal Movement of the tongue whether or not it is actually needed. Heart rate increases, rate (see Table 47.3). Acetylcholine is the neurotransmitter vasodilation in skeletal muscles increases oxygen and glucose at all parasympathetic synapses, both pre ganglionic and supply, bronchioles dilate to tak e in more air , and the li ver postganglionic; it is inactivated by acetylcholinesterase. converts glycogen to glucose to provide energy. The neurotrans- mitters of the sympathetic di vision are acetylcholine and norepinephrine. Acetylcholine is released by sympathetic CRITICAL THINKING preganglionic neurons; its inactivator is acetylcholinesterase. Norepinephrine is released by most sympathetic postganglionic Mrs. Stevens neurons at the synapses with the effector cells; its inactivator is Mrs. Stevens receives albuterol treatments for her catechol-O-methyltransferase (COMT) or monoamine oxidase chronic obstructive pulmonary disease. The medication (MAO). Table 47.3 summarizes both ANS divisions. opens her airways effectively, but after her treatments, she often reports that her heart is racing. What part of Parasympathetic Division the PNS do you think this medication affects? The cell bodies of the parasympathetic pre ganglionic neurons Suggested answers are at the end of the chapter. are craniosacral (in the brainstem and the sacral segments of the spinal cord, Fig. 47.9). The parasympathetic division dominates during relaxed, nonstressful situations to promote normal functioning of se veral organ systems. Digestion proceeds Aging and the Nervous System normally, with increased secretions and peristalsis; defecation With age, the brain loses neurons, b ut this is only a small and urination may occur, and the heart beats at a normal resting percentage of the total and is not the usual cause of mental 4068_Ch47_1095-1117 15/11/14 2:12 PM Page 1104 1104 UNIT THIRTEEN Understanding the Neurologic System Sympathetic preganglionic neurons begin within the spinal cord. From the cell bodies, myelinated fibers reach to sympathetic ganglia, most of which exist in chains along both sides of the spinal cord (even though the illustration here depicts the ganglia only along one side). Because the ganglia lie close to the spinal cord, the preganglionic neurons are short. Not all preganglionic neurons synapse in the first ganglion they encounter. Some travel up or down the chain to synapse with other ganglia at different levels. Others pass through the first ganglion to synapse with another ganglion a short distance away. Unmyelinated postganglionic fibers leave the ganglia and extend to the target organs. Postganglionic fibers tend to be long. FIGURE 47.8 Sympathetic nervous system. From Thompson, G. S. (2013). Understanding anatomy and physiology. Philadelphia: F.A. Davis, p. 188. impairment in older adults; f ar more common causes of because that would be wasted energy, decreased mental changes include depression, malnutrition, infection, urine output so you won’t have to stop for the hypotension, and the side ef fects of medications. Some restroom, and increased mental alertness so forgetfulness is to be e xpected, as is a decreased ability for you are always aware of where the lion is. problem solving (Fig. 47.10). Parasympathetic—P is for PEACEFUL: The parasympathetic nervous system brings the body back to balance and rest. It is sometimes referred to as the rest-and-digest response. LEARNING TIP Think, “There is no longer a lion. Now my body Sympathetic—S is for STRESS RESPONSE: can go back to normal and start digesting and The sympathetic response is referred to as the urinating again!” fight-or-flight response. When thinking of the sympathetic nervous system, imagine getting away from a lion. You need dilated pupils to see the path better, copious production of sweat to NURSING ASSESSMENT OF lose heat through evaporation, increased rate THE NEUROLOGIC SYSTEM and force of heart contraction to ensure that enough blood gets to the extremities so you The focus of a nursing neurologic assessment is to establish can run faster, dilated bronchioles to get more the present function of the patient’ s neurologic system oxygen to your muscles, decreased digestion and to detect changes from previous assessments. A com- plete neurologic assessment, intended to determine the 4068_Ch47_1095-1117 15/11/14 2:12 PM Page 1105 Chapter 47 Neurologic System Function, Assessment, and Therapeutic Measures 1105 TABLE 47.3 FUNCTIONS OF THE AUTONOMIC NERVOUS SYSTEM Organ Sympathetic Response Parasympathetic Response Heart (cardiac muscle) Increase rate Decrease rate (to normal) Bronchioles (smooth Dilate Constrict (to normal) muscle) Iris (smooth muscle) Pupil dilates Pupil constricts (to normal) Salivary glands Decrease secretion Increase secretion (to normal) Stomach and intestines Decrease peristalsis Increase peristalsis for normal digestion (smooth muscle) Stomach and intestines Decrease secretion Increase secretion for normal digestion (glands) Internal anal sphincter Contract to prevent defecation Relax to permit defection Urinary bladder (smooth Relax to prevent urination Contract for normal urination muscle) Internal urethral sphincter Contract to prevent urination Relax to permit urination Liver Change glycogen to glucose None Sweat glands Increase secretion None Blood vessels in skin and Constrict None viscera (smooth muscle) Blood vessels in skeletal Dilate None muscle (smooth muscle) Adrenal glands Increase secretion of epinephrine None and norepinephrine Source: From Scanlon, V. C., & Sanders, T. (2015). Essentials of anatomy and physiology (7th ed.). Philadelphia: F.A. Davis, with permission. existence of neurologic disease, is performed by a health swallowing) may need to ha ve restrictions placed on the care provider (HCP). A baseline neurologic assessment types of food or fluids the y can have. This information should be performed on every patient admission (Box 47-1). must be consistently communicated to all staff involved in In addition to pro viding valuable information about the the patient’s care. current functioning of the patient’ s neurologic system, The frequency of neurologic assessments depends on the the assessment provides baseline data for later comparison. patient’s admitting diagnosis, the presence of an y chronic This is especially important if the patient has chronic neurologic disorders, and the current functioning of the patient’s neurologic deficits on admission. neurologic system. Orders for neurologic assessments v ary Consider a patient admitted for sur gery who has had a from every 15 minutes for an acutely ill or injured patient, to previous cerebrovascular accident resulting in paresis every 8 hours for a patient who is close to being dischar ged, (weakness or partial paralysis) of the right arm.A complete to every 24 hours for a resident li ving in long-term care. It is neurologic assessment would document that the right arm always appropriate to assess a patient more often than ordered, is weaker than the left. If during the postoperati ve course based on observed changes in the patient’ s condition, and to you assess that both arms are equal in strength, you would communicate the findings of those assessments to the HCP. want to notify the physician so the patient could be further Rapid detection and interv ention may mean the dif ference assessed for possible causes of weakening of the left arm. between chronic dysfunction and recovery or even between life The results of the baseline assessment are in valuable and death for the patient. in planning and implementing safe care. F or example, a patient who has a history of seizures needs a safe environ- WORD BUILDING ment and careful monitoring, and all staf f members who cerebrovascular: cerebro—brain + vascular—vessels interact with such patients should be a ware of ho w to paresis: partial paralysis respond to a seizure. P atients with dysphagia (difficulty dysphagia: dys—difficult + phagia—eating 4068_Ch47_1095-1117 15/11/14 2:12 PM Page 1106 1106 UNIT THIRTEEN Understanding the Neurologic System Parasympathetic fibers leave the brainstem by joining one of the following cranial nerves: III Oculomotor nerve (III): Parasympathetic fibers carried in this nerve innervate the ciliary muscle, which thickens VII the lens of the eye, and the pupillary constrictor, which IX constricts the pupil. Facial nerve (VII): These parasympathetic fibers regulate the tear glands, salivary glands, and nasal glands. Glossopharyngeal nerve (IX): The parasympathetic fibers carried in this nerve trigger salivation. Vagus nerve (X): This nerve carries about 90% of all parasympathetic preganglionic fibers. It travels from the brain to organs in the thoracic cavity (including the heart, X (vagus) lung, and esophagus) and the abdominal cavity (such as the stomach, liver, kidneys, pancreas, and intestines). Parasympathetic fibers leave the sacral region by way of pelvic nerves and travel to portions of the colon and bladder. Unlike the ganglia of the sympathetic division, the ganglia of the parasympathetic division reside in or near the target organ. As a result, the preganglionic fibers of the parasympathetic division are long while the postganglionic fibers are short. Because the ganglia are more widely dispersed, the parasympathetic division produces a more localized response than that of the sympathetic division. Pelvic nerves FIGURE 47.9 Parasympathetic nervous system. From Thompson, G. S. (2013). Understanding anatomy and physiology. Philadelphia: F.A. Davis, p. 189. Health History positions and exhibiting signs of discomfort? Is the patient able to move about freely? Is he or she able to carry on a To understand the patient’s neurologic status, ask about past coherent conversation? and current symptoms, use of prescription and o ver-the- counter medications, use of recreational drugs, past surgeries, Physical Examination treatments, and risk factors such as family history, diet, exer- The physical examination begins when you f irst meet the cise, sedentary lifestyle, caffeine intake, and recent stressors. patient and e valuate the patient’ s mental and physical Assessment of symptoms, as with other body systems, status. The neurologic system is assessed using inspection, includes asking the WHAT’S UP? questions. palpation, and percussion (with a refle x hammer). When You should also obtain a history of the patient’ s general conducting the mental status and cogniti ve portions of the health and then focus on any neurologic symptoms. Symptoms examination, be aware that fatigue, illness, or medications of neurologic disorders vary in type, location, and intensity. It can alter findings. When interpreting neurologic findings, be is important to remember that some neurologic disorders sure to consider the patient’s age, educational background, can affect the patient’s ability to think, remember , speak, or and cultural background. interpret stimuli. It may be necessary to question signif icant others about duration and severity of symptoms. Some patients Level of Consciousness may not be able to recognize their own neurologic deficits. In Level of consciousness exists along a continuum from full such cases, the significant other usually initiates contact with wakefulness, alertness, and cooperation to unresponsi ve- the health care system and pro vides the medical and social ness to an y form of e xternal stimuli. A fully conscious history. See Table 47.4 for sample questions to ask if the patient patient responds to questions spontaneously. As conscious- has a change in mental status. ness becomes impaired, a patient may sho w irritability, In addition to questioning the patient, the nurse observ es a shortened attention span, or an inability to cooperate.The the patient during the health history. Is he or she shifting level of consciousness should be the f irst thing assessed 4068_Ch47_1095-1117 15/11/14 2:12 PM Page 1107 Chapter 47 Neurologic System Function, Assessment, and Therapeutic Measures 1107 rapid deterioration in consciousness. When assessing LOC, The Aging consider the patient’s physical ability to respond, taking into Nervous consideration trauma, medical condition, and medications. For System example, a patient who cannot open his or her e yes because of facial trauma may still have an intact neurologic system. Decreased Motor response is scored in the GCS based on following blood flow commands, responding to pain, or displaying abnormal to brain Decreased postural postures. Abnormal postures includes decorticate and Decreased stability Deposition acetylcholine decerebrate. In decorticate, or fle xion, posturing, the of aging pigment lipofuscin in nerve and progressive patient’s arms are flexed at the elbow, the hands are raised cells and amyloid loss of toward the chest, and the legs are extended (Fig. 47.11A). dendrites in blood vessels This posture indicates signif icant impairment of cerebral Decrease in functioning. In decerebrate, or e xtension, posturing, both dopamine the arms and legs are extended and the arms are internally Decrease in norepin- rotated (Fig. 47.11B). This abnormal posturing indicates Increased ephrine syncope damage in the area of the brainstem. Decreased The total possible score on the GCS ranges from 3 to 15. mental Impaired A score of less than 7 indicates a comatose patient and a function short-term memory score of 15 indicates the patient is fully alert and oriented. Impairment When used to score the ef fects of a head injury, a score of Decreased in cognition, motor 13 or 14 indicates mild head injury , 9 to 12 indicates mod - reasoning, function erate injury, and any score of 8 or belo w indicates severe judgment, and orientation head injury. For all categories of the GCS, the type of painful stimuli required to elicit a response should be documented. Altered More Deterioration in the patient’s condition (i.e., a lo wering of sleep accidents the GCS score) should be reported to the physician promptly. patterns and falls See “Evidence-Based Practice.” FIGURE 47.10 Aging and the neurologic system. This concept map shows the effects the aging process has on the neurologic system. EVIDENCE-BASED PRACTICE Clinical Question Is the Glasgow Coma Scale (GCS) the best tool for neurologic assessment? Box 47-1 Basic Neurologic According to a recent study by Sadaka, Patel, Assessment and Lakshmanan (2012), there has been a known problem with the GCS when used with intubated Assess level of consciousness (patient’s response to patients. A new scale has been developed, known verbal or tactile stimulation) and orientation. as the Full Outline of Unresponsiveness scale Obtain vital signs (specifically blood pressure, pulse, (FOUR). Both scales were used to assess level of and respirations). consciousness and predict the patient outcome Check pupillary response to light. after a traumatic brain injury. A high degree of Assess strength and equality of hand grip and movement consistency was found between the two scales. of extremities. The conclusion was that the FOUR scale is an Determine ability to sense touch or pain in extremities. accurate predictor of outcome for TBI patients and had an advantage over the GCS when assessing an intubated patient. The FOUR during a neurologic e xamination because the information evaluates four components: eye and motor obtained can be used to modify the remainder of the responses, brainstem reflexes and respiration. examination if necessary. Keep in mind that a decrease Source: Sadaka, F., Patel, D., & Lakshmanan, R. (2012), The FOUR score in the level of consciousness can be caused by problems predicts outcome in patients after traumatic brain injury. Neurocritical such as hypoxia, hypoglycemia, or intoxication, not just Care, 16, 95–101 doi: 10.1007/s12028-011-9617-5. dysfunction of the neurologic system. Many health care institutions use the Glasgow Coma Scale (GCS), which is an international scale used to assess level of WORD BUILDING consciousness (LOC) and document f indings (Table 47.5). decorticate: de—down + corticate—cerebral cortex The GCS is used to evaluate patients who have a potential for decerebrate: de—down + cerebrate—cerebrum 4068_Ch47_1095-1117 15/11/14 2:12 PM Page 1108 1108 UNIT THIRTEEN Understanding the Neurologic System TABLE 47.4 COLLECTION OF DATA RELATING TO MENTAL STATUS Questions to Ask During Category the Health History Rationale/Significance Mental Status What is your name? What is the month? Disorientation is often an initial sign of a Year? Where are you now? neurologic disorder. Intellectual Subtract 7 from 100, then 7 from that Most people with intact neurologic function can Function answer, and so on (serial 7s). complete serial 7s in about 90 seconds. Thought What would you do if you smelled smoke? Assessment of the patient’s ability to interpret infor- Content Where would you put milk? mation and act appropriately is an important safety issue and activity of daily living. Perception Show patient pencil and pen and ask what Agnosia (inability to interpret or recognize familiar each is. objects) can occur in stroke and brain lesions. Language Read the following sentence: ____. Different types of aphasia can result from Ability injury to different parts of the brain. Memory Repeat these four or five words: ____. Impaired memory can be affected by both delirium Repeat them again in 5 minutes. and dementia. Delirium can cause impaired immediate and short-term memory, whereas dementia not only affects immediate and short- term memory but also the ability to learn new information. It also may be related to stroke. Pain On a scale of 0 to 10 with 0 as no pain and Pain perception may be altered or impaired by spinal 10 as the worst you have ever had, what injury, medications, alcohol, stress, and level of is your pain level? consciousness. Some spinal injuries may be critical, but the patient will not report pain. The Full Outline of UnResponsiveness (FOUR) is a newer TABLE 47.5 GLASGOW COMA SCALE tool that has been introduced into man y critical care and emergency department areas and has been sho wn to be as Eye opening Spontaneous 4 effective if not better than the GCS. A major benefit of using To verbal stimulus 3 the FOUR is that no evaluation of verbal response is neces- To painful stimulus 2 sary, which is a problem when using the GCS with intubated No response 1 patients. The FOUR uses four categories: eye response, motor movement, reflexes, and breathing pattern. A maximum of Verbal response Normal conversation 5 four points can be earned in each of the four areas.The terms Confused conversation 4 decorticate and decerebrate are not used when assessing Inappropriate words 3 the motor response to pre vent confusion. In addition, the Incomprehensible 2 brainstem is e valuated using both pupillary refle xes and sounds corneal reflexes along with the cough refle x. Once each of No response 1 the components is assessed and assigned a numerical v alue, Motor response Obeys commands 6 the components are totaled. In general, the lower the FOUR Localizes pain 5 Score is, the w orse the patient is neurologically and the Withdraws from pain* 4 poorer the prognosis. Conversely, the higher the score, the Abnormal flexion 3 better the prognosis (see Fig. 47.12). Abnormal extension 2 No response 1 Mental Status Mental status can be affected not only by the aging process Note. This scale is for adults only. Criteria specific to children should be but by a variety of neurologic disorders and injuries. A trau- used for pediatric cases. *To elicit pain, place pressure on a nailbed or on the trapezius muscle. matic brain injury can result in memory impairment, delayed Be sure to apply the stimulus long enough to elicit a response. amnesia, affective (mood) disorders, and dementia. To assess 4068_Ch47_1095-1117 15/11/14 2:12 PM Page 1109 Wrists and fingers flexed Feet plantar flexed Legs internally rotated Elbows flexed Arms adducted A Decorticate posturing FIGURE 47.11 Abnormal posturing. Feet plantar flexed Wrists and fingers flexed Arms adducted (A) Decorticate posturing. (B) Decerebrate Forearms pronated Elbows extended posturing. B Decerebrate posturing Eye response 4 ⫽ eyelids open or opened, tracking, or blinking to command 3 ⫽ eyelids open but not tracking 2 ⫽ eyelids closed but open to loud voice 1 ⫽ eyelids closed but open to pain 0 ⫽ eyelids remain closed with pain Motor response 4 ⫽ thumbs-up, fist, or peace sign 3 ⫽ localizing to pain 2 ⫽ flexion response to pain 1 ⫽ extension response to pain 0 ⫽ no response to pain or generalized myoclonus status Brainstem reflexes 4 ⫽ pupil and corneal reflexes present 3 ⫽ one pupil wide and fixed 2 ⫽ pupil or corneal reflexes absent 1 ⫽ pupil and corneal reflexes absent 0 ⫽ absent pupil, corneal, and cough reflexes Respiration 4 ⫽ not intubated, regular breathing pattern 3 ⫽ not intubated, Cheyne-Stokes breathing pattern 2 ⫽ not intubated, irregular breathing 1 ⫽ breathes above ventilator rate 0 ⫽ breathes at ventilator rate or apnea FIGURE 47.12 FOUR Score Coma Scale. From Wijdicks, E. F. M., Bamlet, W. R., Marmatton, B. V., Manno, E. M., & McClelland, R. L. (2005). Validation of a new coma scale: The FOUR Score. Annals of Neurology, 58, 585–593. DOI: 10.1002/ana.20611. Figure 1 and Table 1. Used with permission. © Mayo, 2005. 4068_Ch47_1095-1117 15/11/14 2:12 PM Page 1110 1110 UNIT THIRTEEN Understanding the Neurologic System for cognitive impairment, the Mini-Mental State Examination Pupil gauge (mm) (MMSE) or Confusion Assessment Method can be used. The 2 3 4 5 6 7 8 9 Confusion Assessment Method uses the following criteria to help diagnose delirium (Waszynski, 2007): Acute onset and fluctuating course Inattention FIGURE 47.13 Assessment of pupil size. Disorganized thinking Altered level of consciousness ask the patient or signif icant others if the patient normally Find more about the Confusion Assessment Method at the has unequal pupils. Anisocoria may be congenital; it can also Hartford Institute for Geriatric Nursing (http://consultgerirn.org), be caused by cataract surgery. Development of unequal pupils an excellent collaborative website that provides best practice in a patient who previously had equal pupils is an emergency information related to older adults. A change in mental status and should be reported to the physician immediately. Any should be taken seriously, especially when the patient tak es deviation from the normal round shape of the pupils is multiple medicines or has had a recent change in medicines. documented. A primary cause of delirium and acute states of confusion is Once the resting size of the pupils has been noted, the adverse effects from medications. next step is to assess their response to light. In a darkened When you assess cognitive function, you are evaluating the room, a light source (such as a flashlight) is directed at patient’s thinking capacity. You want to determine the length of the pupil from the lateral aspect of the e ye. This allows attention span, ability to concentrate, judgment, memory, orien- the examiner to see the direct and the consensual response tation, perception, problem-solving ability, and motor function. to the light. A consensual response means that when You can learn a great deal about a patient’s mental capaci- one pupil is e xposed to direct light, the other pupil also ties and emotional state by simply interacting with the patient. constricts. Absence of a consensual response may indicate Behavior, mood, hygiene, grooming, and choice of dress reveal a pathological condition in the area of the optic chiasm. pertinent information about mental status. Mental status exam- Typically, the speed of the reaction to light is described as inations can be performed to determine patients’ cognitive brisk, sluggish, or absent. Differences in the speed or size functioning, thought processes, and perceptions by observing of constriction between the two pupils should be reported the patient’s verbal and nonverbal responses to questions and to the practitioner. specific requests. Table 47.4 includes some w ays to assess Accommodation is the process of visual focusing from these areas. far to near. To evaluate for accommodation, have the patient Orientation refers to the patient’s ability to comprehend focus on an object at a distant point and then refocus on himself or herself in relation to person, location (place), and the object at a near point. Pupils should constrict with time. A patient who is fully oriented is often referred to as the adjustment to the near object and the eyes should con- “oriented times three.” Typical questions include, “What is verge. Upon completion of the assessment of the pupils, your name? Where are you? What day is it?” (Keep in mind document your f indings. PERRLA is a commonly used that we all forget the date from time to time!) You can also abbreviation to note that pupils are equal, round, and reac- ask if the person knows what season it is (spring, fall, etc.). tive to light and accommodation. Note, if you ha ve not A resident of a long-term care f acility who says he is “at assessed for accommodation, then do not include the A in home” may consider the facility his home and is not neces- the acronym. sarily disoriented. Be sure your question is appropriate to You will also e valuate for range of motion and for the patient’s age, culture, li ving conditions, lifestyle, and smoothness and coordination of movements. Eyes that move medical condition. If the patient is unable to speak because in the same direction in a coordinated manner are said to of a stroke (expressive aphasia) or being intubated, do not have a conjugate gaze. Conversely, a dysconjugate gaze is rule out the possibility that the patient is oriented. Gi ve movement of the eyes in different directions. Some patients expressively aphasic patients yes-or -no questions such as may be unable to move one or both eyes in a specific direc- “Are you in a grocery store?Are you in a bowling alley? Are tion; this is called ophthalmoplegia. It is often documented you in a hospital?” P atients may be able to answer with a as “limited extraocular movements.” Always document what shake of the head, eye blinks, or hand squeezes as instructed. the limitation is (e.g., “Patient is unable to look laterally with left eye”). This allows colleagues to compare their findings Examination of the Eyes with yours and detect any changes. Examination of the pupils is an important part of the neuro- Nystagmus is involuntary movement of the eyes. Nystag- logic assessment and cranial nerve evaluation. The size of the mus varies in the speed of the mo vement and the direction. pupils at rest is documented in millimeters (Fig. 47.13). If Horizontal nystagmus is the most common. Common causes the patient’s pupils are unusually lar ge or small, determine whether the patient has had an y medications that can WORD BUILDING affect pupil size. If the patient’ s pupils are unequal in size aphasia: a—absence + phasia—speech (anisocoria), without a correlating diagnosis or symptoms, anisocoria: aniso—unequal + coria—pupil 4068_Ch47_1095-1117 15/11/14 2:12 PM Page 1111 Chapter 47 Neurologic System Function, Assessment, and Therapeutic Measures 1111 of nystagmus are phenytoin (Dilantin) toxicity and injury to to straighten the leg at the knee. The hamstrings are responsi- the brainstem. ble for knee fle xion and are evaluated by having the patient attempt to keep the heel of the foot against the bed or chair Examination of Muscle Function rung. Dorsiflexion is tested by having the patient pull the toes Examine muscle groups systematically in the upper extremities toward the head against resistance. Plantar flexion is tested by and then the lower extremities, comparing right to left. Com- having the patient push against the examiner’s hand with the pare muscle groups for symmetry of size and strength. K eep ball of the foot. in mind the patient’s age and general physical condition when Babinski’s reflex is tested by firmly stroking the sole of the evaluating muscle strength. You would not expect the same foot. Normal response is flexion of the great toe. If the great amount of strength from a 75-year -old woman as from a toe extends and the other toes fan out, neurologic dysfunction 20-year-old man. If the patient has chronic neurologic deficits, should be suspected if the patient is more than 6 months old. ask if the results of the assessment are dif ferent from his or Deep tendon reflexes are not usually part of a routine nursing her usual level of function. assessment. The patient’s gait should be assessed to detect any Many HCPs use a 5-point scale to document muscle neurologic dysfunction and also to assess ability to ambulate strength. A score of 5 describes a patient who is able to mo ve safely. Patients who stagger, weave, or bump into objects may the extremity against gravity and the resistance of the examiner, need assistance with walking. displaying normal muscle strength. If the e xaminer is able to Romberg’s test is performed by ha ving the patient stand provide more resistance than the patient can o vercome with with feet together and eyes closed. Be sure to stand close to active movement, the score is 4. If the patient can mo ve the the patient, especially if he or she is an older adult, to prevent extremity only against gravity, but not resistance, the score is falling. A negative Romberg’s test means that the patient 3. If gravity must be eliminated by having the examiner support experiences minimal swaying for up to 20 seconds.A patient the extremity to allow the patient to mo ve the extremity, the who experiences swaying or who leans to one side is said to score is 2. A score of 1 is given if there is no active movement have a positive Romberg’s test. A positive Romberg’s test of the e xtremity, but a minimum muscular contraction can may be seen in cerebellar dysfunction. be palpated. If the e xaminer is unable to detect an y muscular function, a score of 0 is given. To test the deltoid muscles, ask the patient to raise his or her arms at the shoulder. Have the patient resist as you BE SAFE! push down on the upper arms. The biceps are tested by hav- A positive Romberg’s test in an older adult is ing the patient flex the arm at the elbow and bring the palm expected as a result of normal aging changes in toward the face, then resist as you attempt to straighten the the cerebellum. Be sure to protect the patient arm by pulling on the forearm. With the arm similarly with a positive result from falls. A gait belt may be flexed, ask the patient to straighten the arm while you resist helpful when assisting the patient with ambulation. the movement. Hand grasps are tested by having the patient squeeze your fingers. Remember to cross your index and middle fingers to prevent the patient from hurting your f ingers. If the patient does not release the grasp when told to, it is a reflex grasp, not Examination of Cranial Nerves a response to command. A reflex palmar grasp may indicate The cranial nerves are usually not examined in depth during a pathological condition of the frontal lobe. a routine bedside neurologic assessment. Testing requires a Assess for arm drift by asking the patient to hold both patient who is able to cooperate with the examiner. Table 47.6 arms straight in front with the palms upw ard while keeping provides basic testing techniques that offer a basic assessment the eyes closed. A downward drift of the arm or rotation so of cranial nerve function. that the palm is do wn indicates impairment of the opposite side of the brain. If a pathological condition is present, arm Summary of Examination Findings drift may be apparent before dif ferences in muscle strength In all cases, the findings of the neurologic examination should can be detected. be correlated with the remainder of the physical examination Assessment of leg muscle strength be gins with the iliop- findings. A decreased level of consciousness, coupled with a soas muscle. Place your hand on the patient’ s thigh and ask decreased oxygen saturation on pulse oximetry , point to the patient to raise the le g, flexing at the hip. Hip adductors hypoxia as a cause. Correlation of vital signs with neurologic are tested by having the patient bring his or her legs together signs is particularly important. Bradycardia, increasing against your hands. The hip abductors and gluteus medius and systolic blood pressure with widening pulse pressure, and minimus are tested by having the patient move the legs apart irregular respirations, commonly referred to as Cushing’ s against resistance. Hip e xtension by the gluteus maximus is triad, are late indications of increasing intracranial pressure. tested by placing the hand under the thigh and ha ving the These findings, in conjunction with a unilateral dilated pupil, patient push do wn with the le g. The quadriceps femoris may indicate impending herniation of the brain (discussed |extends the knee and is tested by ha ving the patient attempt further in Chapter 48). 4068_Ch47_1095-1117 15/11/14 2:12 PM Page 1112 1112 UNIT THIRTEEN Understanding the Neurologic System TABLE 47.6 COLLECTION OF DATA RELATED TO CRANIAL NERVE FUNCTION Nerve Test Olfactory nerve Ask patient to identify common scents, such as cinnamon and coffee. Optic nerve Ask patient to read something or tell how many fingers you are holding up. Oculomotor nerve Check pupils for reaction to light and accommodation. Oculomotor, trochlear, Ask patient to follow your finger while moving it in front of his or her eyes in the positions and abducens nerves of a clock: 1, 3, 5, 7, 9, and 11 o’clock. Trigeminal nerve Ask patient to identify touch on different parts of the face with eyes closed. Facial nerve Ask patient to frown, smile, wrinkle forehead; check for symmetry. Vestibulocochlear nerve Have patient identify whisper close to each ear. Observe gait for balance. Glossopharyngeal and Watch for uvula and palate to rise when patient says “ahh.” Touch back of throat with vagus nerves cotton-tipped applicator to elicit gag reflex. Spinal accessory nerve Ask the patient to turn head and shrug the shoulders against resistance. Hypoglossal nerve Ask the patient to stick out the tongue and move it from side to side. research lab (VDRL) test (for syphilis), li ver function, CRITICAL THINKING and renal function. Measurement of erythrocyte sedimenta- tion rate (ESR) and white blood cell (WBC) count may Tim Thompson indicate an infection, such as meningitis. Hormone le vels, You are caring for Tim, a 78-year-old man admitted such as prolactin or cortisol, may indicate dysfunction of the with heart problems. As you enter his room with his pituitary gland related to a brain tumor. Anticholinesterase afternoon medications, you f ind Tim confused. He testing and antibody titers are useful in diagnosing myasthenia thinks he is at home, that the year is 1968, and he gravis. Research is ongoing to de velop a blood test for does not understand who you are or why you are there. Alzheimer’s disease. He recognizes his wife, who is at his bedside, and he knows his own name. Lumbar Puncture Cerebrospinal fluid (CSF) may be obtained via lumbar puncture 1. How would you describe and document his mental and evaluated for glucose and protein le vels, the presence of status? bacteria and WBCs, levels of immunoglobulin, antibodies, and 2. What additional data do you need to decide how to culture and sensitivity. See Appendix A for nursing care of a proceed? patient undergoing lumb