The Nervous System

Faith Frances L.Libarios RN

 An important aspect of the Neurological

HISTORY OF THE PRESENT ILLNESS.

Assessment is THE

HEALTH HISTORY
Should include Onset Character Severity Location Duration Frequency of s/sx Associated complaints
 Precipitating and aggravating factors  Progression, remission and exacerbation  Presence or absence of similar symptoms among family members  Review of medical history  History of fall or trauma  Use of alcohol, medications and illicit drugs

Cardinal signs and symptoms indicating altered neurologic functions

1. Pain unpleasant sensory perception and emotional experience associated with actual or potential tissue damage. Entirely subjective. Can be acute or chronic. 2. Seizures the result of abnormal paroxysmal discharges in the cerebral cortex, manifests as an alteration in sensation, behavior, movement, perception or consciousness. May be the first obvious sign of a brain lesion.

3. Dizziness and vertigo- an abnormal sensation of imbalance or movement. Vertigo an illusion of movement, usually rotation. Usually, a manifestation of vestibular dysfunction. May result in spatial disorientation, light headedness, loss of equilibrium (staggering), nausea and vomiting.

4. Visual disturbances- can range from the decreased visual acuity associated with aging to sudden blindness cause by glaucoma. Normal vision on functioning visual pathways through the retina and optic chiasm and the radiations into the visual cortex in the occipital lobes.

5. Weakness muscle weakness is a common manifestation of neurologic disease. Frequently co exists with other symptoms of disease. Can be sudden and permanent or progressive. 6. Abnormal sensation- numbness, abnormal sensation or loss of sensation is a neurological manifestation of both CNS and PNS

B. Physical Examination
Neurologic examination- a systematic process that includes a variety of clinical tests, observations and assessments designed to evaluate the neurologic status of a complex system. Various assessments tools (e.g. Glasgow Coma Scale) may be used to assess the clients LOC.

A Neurological Assessment is divided into Five Components

I. Cerebral Function II. Cranial Nerves III.Motor System IV.Sensory System V. Reflexes
Follows a logical sequence and progresses from higher levels of cortical function (ex. Abstract thinking) to lower level of function (ex. Determination of the integrity of the peripheral nerves)

I. Assessing Cerebral Function

Interpretation and documentation of neurologic abnormalities, particularly mental status abnormalities should be SPECIFIC

AND

NONJUDGMENTAL.

Mental status
Observe the patients a. Appearance b. Behavior c. Noting dress d. Grooming e. Personal hygiene f. g. h. i. j. k. Posture/ gesture Facial expressions Motor activity Manner of speech LOC Orientation (time, place and person)

STATE OF AWARENESS
STATE DESCRIPTION Alert: oriented to time, place, person; understands verbal and written words Not oriented to time, place or person Reduced awareness, easily bewildered, poor memory, misinterprets stimuli, impaired judgment Extreme drowsiness but will respond to stimuli Can be aroused by extreme or repeated stimuli Will not respond to verbal stimuli

Full Consciousness Disoriented Confused Somnolent Semicomatose Coma

Intellectual Function
Serial 7s Interpretation of well known proverbs or idioms Capacity to recognize similarities Judgments

Thought Content
Is the patients thoughts Spontaneous Natural Clear Relevant Coherent Check : illusions, hallucinations, preoccupations

Emotional Status
Assess Affect Mood Consistency of verbal communication to non verbal cues

Perception
The examiner may consider more specific areas of higher cortical function. Agnosia- inability to recognize and interpret objects seen through the special senses.

Types of Agnosia and corresponding sites of lesions

Types of Agnosia Affected Cerebral Area

Visual Auditory

Occipital lobe Temporal lobe (lateral and superior portions) Parietal lobe

Tactile

Body parts and relationships Parietal lobe (posteroinferior regions

Motor Ability
Ask client to perform a skilled act ( throw a ball, move a chair) Successful performance requires the ability to understand the activity desired and normal motor strength.

Language Ability
Aphasia deficiency in language function A. Brocas Aphasia ( non- fluent aphasia)- speech output is severely reduced and is limited to short utterances of less than four words Ex. Do, do, rock, yah.

B. Wernickes Aphasia ( fluent aphasia)- ability to grasp the meaning of spoken words is chiefly impaired, while the ease of producing connected speech is not much affected. Ex. I called my mother on the television and did not understand the door. It was too lunch but they came far to near. My mother is not too old for me to be young.

C. Global Aphasia- most severe form of aphasia and is applied to patients who can produce few recognizable words and understand little or no spoken language. Global aphasics can neither read or write.

II EXAMINING CRANIAL NERVES

Cranial nerve I. Olfactory Nerve Clinical examination Each nostril should be patent. Have the patient occlude on and then the other during testing. With the eyes closed, a patient should be able to identify common smells such as cinnamon, coffee, vanilla or cloves. read a Snellen Eye Chart from a distance of 20 feet (6 meters). The patient covers one eye at a time and reads to smallest line possible. Opthalmoscopic examination

II. Optic Nerve

III. Oculomotor Nerve, IV. Trochlear Nerve, VI. Abducens Nerve V. Trigeminal Nerve

Test for ocular rotations, nystagmus, conjugate movements, test for pupillary reflexes, ptosis Eyes closed, touch forehead, cheeks and jaw for sensitivity to sharp objects. If responses are incorrect, test for temperature sensation. While looking up lightly touch a wisp of cotton against each cornea ( normal response: blinks and tears) Have client clench and move the jaw from side to side.

VII. Facial Nerve

Observe his facial expression during normal conversation check for any asymmetry, tics, or other facial movements, ask the patient to smile, frown, puff out his cheeks. Assess taste:drop a few drops of sweet or salty water on the front part of the tongue and see how it tastes to your patient. Whisper or watch tick test Test for lateralization (Weber test) Test for air and bone conduction(Rinne test) Assess patients ability to swallow and discriminate between sugar and salt on posterior 3rd of the tongue

VIII. Acoustic Nerve

IX. Glossopharyngeal Nerve

X. Vagus Nerve

Assess gag reflex, note any hoarseness,check ability to swallow. Patient say ah , symmetrical rise of uvula and soft palate Palpate and note strength of trapezius muscles while patient shrugs shoulders against resistance. Next place one hand on the side of the patient's jaw and the other on the opposite sternocleidomastoid muscle. Have the patient turn his head towards the hand on his jaw while you apply slight resistance. Observe the strength in both muscles. Repeat to the other side.

XI. Spinal Accessory Nerve

XII. Hypoglossal Nerve

This nerve is tested by listening to the patient's articulation as he speaks as well as observing for any atrophy or deviation of the tongue while speaking. Have the patient stick his tongue out and move it from side to side. Check for symmetry of movement. Have the patient push his tongue against the inside of each cheek and you palpate for strength from the outside of his cheek.

III. EXAMINING THE MOTOR SYSTEM

Assess muscle size, tone and strength, coordination and balance. Note for rigidity, spasticity, and flaccidity.

Muscle Strength Grading

0 No contraction 1 Slight contraction, no movement 2 Full range of motion, without gravity 3 Full range of motion with gravity 4 Full range of motion, some resistance 5 Full range of motion, full resistance

Balance and Coordination

Rapid, alternating movements Point to point testing Ataxia incoordination of voluntary muscle action Roomberg Test

IV. EXAMINATION OF REFLEXES

Stretch or Deep Tendon Reflexes - A brisk tap to the muscle tendon using a reflex hammer produces a stretch to the muscle that results in a reflex contraction of the muscle. The muscles tested, segmented level and grading is listed below: - Grading DTR 0- absent 1 decreased but present 2 normal 3 brisk and excessive 4- with clonus

Reflexes
Biceps reflex Triceps reflex Brachioradialis reflex Patellar reflex Ankle reflex Superficial reflexes Corneal Abdominal reflex Gag Cremasteric Plantar Perianal

V. Sensory Examination
Largely subjective and requires coordination Assessment of the sensory system involves Tactile sensation Superficial pain Vibration Integration of sensation Proprioception Stereognosis

Laboratory and Diagnostic Studies

Computed tomography Scanning

 Provides cross- sectional views of the brain and helps to identify pathologies, such as tumors, hematomas and edema. Noninvasive, painless Nsg Interventions: Teach patient to lie quietly throughout procedure Relaxation techniques Sedation if necessary Assess for iodine/shellfish allergy if contrast agent is used. Watch out for allergic reactions and other side effects (flushing, nausea and vomiting)

Magnetic Resonance Imaging

Uses a powerful magnetic field to obtain images of different areas of the body that are used to identify cerebral abnormalities. Nsg. Interventions Teach relaxation techniques Remove all metal objects, credit cards, medication patches with metal backing No metal objects in the MRI room, O2 tanks, ventilators, stethoscopes Presence of any metal objects in the patient.( aneurysm clips, orthopedic hardware, pacemakers, artificial heart valves, intrauterine devices), may malfunction ,dislodge or heat up as they absorb energy.

 Implementation postprocedure client may resume normal activities expect diuresis if a contrast agent was used

Lumbar puncture
Insertion of a spinal needle through L3L4 interspace into the lumbar subarachnoid space to obtain cerebrospinal fluid (CSF), measure CSF fluid or pressure, or instill air, dye or medications Contraindicated in clients with increased intracranial pressure, because the procedure will cause a rapid decrease in pressure within the CSF around the spinal cord, leading to brain herniation

Implementation preprocedure
obtain a consent have the client empty the bladder Implementation during the procedure position the client in a lateral recumbent position and have the client draw knees up to the abdomen and chin onto the chest Assist with the collection of specimens (label the specimens in sequence) Maintain strict asepsis

Implementation postprocedure
Monitor vital signs and neurological signs Position the client flat as prescribed Force fluids Monitor I & O

Myelogram
Injection of dye or air into the subarachnoid space to detect abnormalities of the spinal cord and vertebrae Implementation preprocedure Obtain a consent Provide hydration for at least 12 hours before the test Assess for allergies to iodine Premedicate for sedation as prescribed

 Implementation postprocedure if a water-based dye is used, elevate the head 15 to 30 degrees for 8 hours as prescribed If an oil-based dye is used, keep the client flat 6 to 8 hours as prescribed If air is used, keep the head lower than the trunk as prescribed

Cerebral angiography
Injection of contrast through the femoral artery into the carotid arteries to visualize the cerebral arteries and assess for lesions Implementation preprocedure obtain a consent Assess the client for allergies to iodine and shellfish Encourage hydration for 2 days before the test NPO 4 to 6 hours prior to the test as prescribed Mark the peripheral pulses Remove metal items from the hair

 Implementation postprocedure Monitor for swelling in the neck and for difficulty swallowing and notify the physician if these symptoms occur Elevate the head of the bed 15 to 30 degrees only if prescribed Keep the bed flat if the femoral artery is used, as prescribed Assess peripheral pulses Immobilize the puncture site for 12 hours as prescribed Apply sandbags and a pressure dressing to the injection site as prescribed Force fluids

Electroencephalography
A graphic recording of the electrical activity of the superficial layers of the cerebral cortex Implementation preprocedure Wash the clients hair Inform the client that electrodes are attached to the head and that electricity does not enter the head Withhold stimulants, antidepressants, tranquilizers, and anticonvulsants for 24 to48 hours prior to the test as prescribed Implementation postprocedure Wash the clients hair

THANK YOU!