Assessing the Neurological System PDF

Assessing the Health Neurologica Assessment l System Property of Susan L. Arnold, RN, MSN, ACUE Anatomy and Physiology The brain is the largest part of the central nervous system (CNS)  Cerebrum is the largest portion of the brain  Cerebr...

Assessing the Health Neurologica Assessment l System Property of Susan L. Arnold, RN, MSN, ACUE Anatomy and Physiology The brain is the largest part of the central nervous system (CNS)  Cerebrum is the largest portion of the brain  Cerebral cortex is outer covering of the cerebrum, divided into four lobes (highest level of function)  Frontal lobe  Broca’s area - motor control of speech (Expressive aphasia)  Parietal – integrate sensory information  Temporal – interpretation of smell, sound, language  Wernicke’s area – language comprehension (Receptive aphasia)  Occipital – interpret visual stimuli and light  Cerebellum – back of brain; coordination, movement, speech, and senses  Brainstem – posterior part of brain; central core of brain, involuntary functions (breathing, heart rate, cough, sleep, and consciousness Diagnostics  Computed tomography scan (CT scan)  Electroencephalogram (EEG)  Lumbar puncture  Magnetic resonance imaging (MRI)  Positron-emission tomography scan (PET)  Cerebral angiography Diagnostics  CT Scan - when CNS disease is suspected; can identify congenital abnormalities, fractures, brain tumors, infarction, bleeding, and hematomas.  EEG – graphic recording of the brain’s activity; used for seizures, epilepsy, head injury, dizziness, headaches, brain tumors, and sleeping issues. EEG is also used to confirm brain death.  Lumbar puncture – needle placed in the subarachnoid space in the spinal column to measure pressure and obtain CSF for analysis; used to diagnose metastatic brain or spinal cord neoplasm, meningitis, cerebral hemorrhage, and encephalitis.  MRI – more detailed images of organs and tissues.  PET Scan – highly detailed images of body functions such as metabolism, blood flow, and oxygen use. Used in early diagnosis of cancer, spread of cancer, brain and heart disease, CNS disorder, head injury, and seizures.  Cerebral angiography – (brain angiogram) a minimally invasive procedure that uses X-rays and a special dye to examine the blood vessels in the brain. It's used to identify or confirm issues with the blood vessels, such as blockages, aneurysms, or other abnormalities.   The brain consists of which of the following three parts? (select all that apply) A. Cerebrum Question B. Frontal lobe C. Cerebellum D. Brain stem   Correct answer: A, C, D  The cerebrum, cerebellum and brain stem are the three Answer parts of the brain.  The frontal lobe is a lobe within the cerebrum. Health History  General Health – “How have you been feeling?”  Affect (mood, emotions, or feelings) and behavior  Family history - stroke, seizures, or neurological genetic disorders  Social history - recreational drugs, alcohol or tobacco increase the risk for stroke and injury.  Nutrition -  High cholesterol diet increases risk for stroke d/t plaque buildup in the arteries  Headache triggers such as MSG, cold foods, red wine, deli meats, caffeine, chocolate and aged chesses  Exercise - Contact sports can increase risk for traumatic brain injury (TBI)  Sleep and rest patterns  Sleep apnea, sleep deprivation, drowsiness  Stress  Skin  Neuropathies – numbness, tingling, or loss of sensation Health History  Transient ischemic attack (TIA) – temporary loss of blood flow to the brain  Loss of sensation, numbness, difficulty speaking, double vision, facial drooping, dysphagia, dizziness  Head, ears, eyes, nose, throat  Change in senses could indicate cranial nerve damage (vision, smell, hearing, taste, touch)  Types of headaches  Migraine  Tension  Cluster  Dizziness or vertigo  Seizure activity  Changes in speech  Difficulty swallowing Health History  Respiratory  Difficulty breathing  Hypoxia  Cardiovascular problems  Atrial fibrillation  Cerebral vascular accident (CVA)  Ischemic stroke  Hemorrhagic stroke Health History  Hands become numb or change color  Paresthesia  Gastrointestinal changes  Nausea or projectile vomiting  Bowel or bladder impairment/incontinence  Musculoskeletal  Difficulty walking or muscle weakness  Myasthenia  Multiple sclerosis (MS) Health History  Endocrine disorders  Diabetes increases the chance of peripheral neuropathies  Thyroid disease can cause dizziness  Hematological disorders  Coagulation disorders can increase risk of blood clots Common Terms  Seizure – abnormal electrical activity in the brain.  Neuropathy – loss of sensation that may feel like numbness, tingling, loss of feeling.  Aphasia – complete impairment of comprehension and expression of speech, understanding language, reading and writing.  Receptive aphasia – unable to understand language in written or spoken form.  Expressive aphasia – unable to communicate language in written or spoken form.  Dysphasia – partial impairment of language and speech.  Dysphagia – difficulty swallowing food or liquids.  Dizziness – feeling lightheaded, faint, and weak.  Vertigo – sensation of moving or having surroundings moving. Common Terms  Ataxia – defective muscle coordination (loss of position sense, drugs, alcohol, or cerebellar disease)  Nuchal rigidity – neck stiffness and pain (meningitis)  Hypoxia – lack of oxygen supply to the brain; change in mental status.  Cerebral vascular accident (CVA) – stroke  Atrial fibrillation – increases risk of stroke  Paresthesia – burning, tingling, or prickling sensation  Myasthenia – lack of muscle tone/strength  Myasthenia gravis – chronic autoimmune causes weakness of voluntary muscles  Multiple sclerosis (MS) – abnormal response of the immune system directed against the nervous system  Parkinson’s – progressive neurodegenerative disorder; inability to control movement Common Terms  Hypotonia – decreased muscle tone  Hypertonia – increased muscle tone  Flaccidity – loss of muscle tone  Rigidity – muscles are contracted and tense; seen with Parkinson’s  Spasticity – increased motor tone causing tight muscles and stiffness  Quadriplegic – absence of movement and sensation in upper and lower extremities.  Paraplegic – absence of movement and sensation in lower extremities.  Hemiparesis – loss of muscle tone and strength to one side of the body (stroke or neurological injury/disease) Posturing General Routine Screening  Assess:  Level of consciousness  Behavior and conduct  Dress/Attire, grooming, and hygiene  Facial expressions  Speech  Mood, feelings, expressions  Visual acuity; six cardinal signs  Posture, gait, balance, involuntary movements  Pain Assessing Level of Consciousness  Purpose: To assess level of consciousness  Mental status assesses for:  Orientation  Memory  Level of consciousness  Mini-Mental State Examination (MMSE)  Assessing Level of Consciousness Normal Findings: Abnormal Findings:  Alert  Disoriented or confused  Oriented to  Drowsy or lethargic  Person  Sleepy  Place  Coma  Time  Situation Glasgow Coma scale  Glasgow Coma Scale (GCS)  Evaluates eye response, motor response and verbal response by checking, observing and stimulating.  Scale is based on a score of 3-15.  A score of 15 is the highest score indicating the patient is awake, alert and oriented.  Glasgow Coma Scale Normal Findings: Abnormal Findings:  Patientis able to  Patientis not able to state state their correct their correct name, date, name, place, and or time time  GCS < 15  GCS = 15 Glasgow Coma Scale   A patient presents to the emergency room with the following assessment: awake, alert but confused, obeys commands by moving Questio extremities. Calculate the GCS. n A. 15 B. 10 C. 14 D. 12 TABLE 17-5 Glasgow Coma Scale Observation Response Elicited Score Eye response Opens spontaneously 4 Opens to verbal command 3 Opens to pain 2 No response 1 Motor response Reacts to verbal command 6 Identifies localized pain 5 Flexes and withdraws from pain 4 Assumes flexor posture 3 Assumes extensor posture 2 No response 1 Verbal response Is oriented and converses 5 Is disoriented but converses 4 Uses inappropriate words 3 Makes incomprehensible sounds 2 No response 1   Correct answer: C  Best eye response is 4.  Best verbal response is 4. Answer  Best motor response is 6.  Total = 14  Mini-Mental State Exam (MMSE) TABLE 17-4 Sample Items from the Mini-Mental State Examination (MMSE) Orientation to Time What is the date? Listen carefully. I am going to say three words. You say them back after I stop. Ready? Here they are: Registration apple (pause) penny (pause) table (pause) Now repeat those words back to me. (Repeat up to five times, but score only the first trial.) Naming What is this? (Point to a pencil or pen.) Please read this and do what it says. Reading (Show examinee the stimulus form.) Close your eyes. Healthy People 2030  Teach the patient to recognize the warning signs of stroke utilizing the mnemonic F.A.S.T.  Face drooping: Ask the person to smile, is the smile uneven or does one side of the face droop?  Arm weakness: Ask the person to raise both arms. Does one arm drift downward; is one arm weak or numb?  Speech difficulty: Ask the person to repeat a simple phrase. Is speech slurred or strange, can the person speak clearly?  Time: If the person exhibits any of these signs, call 9-1-1 immediately..