Neurologic System

Chapter 25

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 Cerebral Function

• Frontal lobe- primary motor

cortex
• Parietal lobe- sensory cortex
• Temporal lobe- auditory
cortex
• Occipital lobe- visual cortex

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 Lobes of the Brain

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 Health History: Risk Factors
• Brain attack, cerebrovascular accident
(CVA)
– Age: older at greater risk
– Gender: men at greater risk than women
(women – more than half of deaths from
brain attacks)
• Pregnant women at higher risk than nonpregnant
• Women who take birth control pills and smoke or
have hypertension
– Family history: risk greater if parent,
grandparent, or sibling had a brain attack
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 Health History: Risk Factors
• Brain attack (cont’d)
– Race: African Americans at higher risk of death
from brain attack
– Previous brain attack or heart attack increases
risk of brain attack
– High blood pressure—undue pressure on
arteries

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 Health History: Risk Factors
• Brain attack (cont’d)
– Diabetes mellitus contributes to hypertension,
hypercholesterolemia, and blood clot
formation
– Coronary artery disease narrows carotid
vessels (reduces blood flow to the brain)
– Transient ischemic attack (TIA)—warning sign
of inadequate blood flow to brain

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 Health History: Risk Factors
• Brain attack (cont’d)
– Atrial fibrillation—blood clots in atrium; travel
to brain
– High serum cholesterol—plaques in vessels,
impairing blood flow
– Obesity increases workload on heart and risk
of high cholesterol and physical inactivity
– Excessive alcohol intake increases blood
pressure
– Cocaine use increases risk
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 Health History:
Present Health Status
• Noticed changes in ability to move
around/participate in usual activities
• Chronic diseases? High blood pressure?
Myasthenia gravis? Multiple sclerosis? Describe.
How does this keep you from maintaining
healthy lifestyle?
• What medications taking? Taking as prescribed?
• How much alcohol per week? Use/ever used
marijuana, cocaine, barbiturates, tranquilizers,
or other mood-altering drugs?

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 Health History:
Past Medical History
• Injury to head/spinal cord? Describe. Changes
since injury?
• Surgery on brain, spinal cord, or nerves? When?
Outcome?
• Stroke? Describe. When? Changes resulting
from stroke?
• Seizure disorder? Describe kind and how often.
What prevents seizures?

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 Problem Based History
Dizziness- TIA
• How do you feel when dizzy or lightheaded?
Feel as if you can’t keep balance or may fall?
How often? Is the dizziness associated with
change in position/activity? What makes it
worse? What relieves it?
• Ever feel like room is spinning (objective vertigo)
or that you are spinning (subjective vertigo)?
Suddenly or gradually? What makes it worse?
What relieves it?

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 Problem Based History
Seizures
• How often are you having seizures/convulsions?
Last seizure? Become unconscious?
• Warning signs before seizure? Describe what
happens.
• Feeling after the seizure? Confused? Headache
or aching muscles? Do you spend time
sleeping?
• Factors that seem to start seizures—stress,
fatigue, activity, or discontinuing medication? Did
you take actions to prevent hurting yourself?
• How has life been affected? Occupation? Wear
identification indicating seizures?
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 Problem Based History
Loss of Consciousness
• When did you lose consciousness or feel
you weren’t aware of surroundings? Did it
occur suddenly? What happened just
before? Other symptoms? Have diabetes
mellitus, liver failure, or kidney failure?
• A change in the level of consciousness if
the most specific indicator of neurologic
alterations.

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 Problem Based History
Changes in Movement
• How long have you had a change in your
mobility? Describe. Continuous or intermittent?
• Noticed tremors/shaking of hands/face? When
started??
• Noted any twitches or sudden jerks?
• Felt any weakness in or difficulty moving body parts?
Confined to one area? Associated with any particular
activity?
• Problems with coordination? Difficulty keeping balance
when walking? Lean to one side/fall?

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 Problem Based History
Changes in Sensation
• Where are you experiencing numbness or
tingling? Associated with any activity?

Problem Based History

Difficulty Swallowing (Dysphagia)
•How long have you had the problem? Have
excessive saliva or drooling? Did you cough or
choke when trying to swallow?
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 Problem-Based History
Difficulty Communicating
(Aphasia/Dysphasia)
• How long have you had problems speaking?
Difficulty forming words or finding right
words? Difficulty understanding things said
to you? Has handwriting changed? When did
that begin? How long did it last?

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 Examination
Procedures and Techniques
• Evaluate speech
• Test eyes—visual acuity (CN II)/peripheral vision
– Snellen chart
– Confrontation test
– Give them something to read
• Observe eyes for extra ocular movement
• Observe eyes—pupillary size, shape, equality,
constriction, accommodation
– PERRLA

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 Examination
Procedures and Techniques
• Test ears—hearing/balance
– Finger rub, Whisper test,

• Inspect oropharynx—gag reflex/soft palate

movement
“aahhhh” test – raise symetrically
– Touch posterior pharynx with tongue blade
– Check soft and hard palate with gloved fingers

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 Examination
Procedures and Techniques
• Inspect tongue—movement, symmetry,
strength, absence of tumors
– Have client protrude tongue, move toward
nose, chin, side to side
• Test shoulder/neck muscles—
strength/movement
– Have client shrug shoulders; turn head to side
against hands

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 Examination
Procedures and Techniques

• Test cerebellar function—balance/coordination

– General observation—observe walking
– Balance
• Romberg test (client standing)—feet together, arms at
side, eyes open/closed
• Alternately touch nose with index fingers (eyes closed)
• Touch each finger to thumb in rapid sequence

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 JOMACS
• Judgement
• Orientation
• Memory (remote, long-term, short-term
• Affect
• Consciousness
• Speech

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 Examination
Deep Tendon Reflexes

• Most are not checked

– + Babinski’s is when the foot is stroked and
the great toe dorsalflexes with fanning of the
toes– pyramidal signs—
– Achilles tendon – pull up on ankle– this
response may be diminished in older adult.

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Deep Tendon Reflexes, Babinski’s and
Achilles Tendon

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 Additional Assessment for
Special Cases
• Orientation
– If orientation a concern during history,
determine if oriented to time, place, person
• Date/time—first orientation to disappear
– Only a problem if remains disoriented after
being reoriented
• Place—2nd orientation to disappear
• Person—last orientation to disappear
– Orientation returns in opposite order in which is lost

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 Additional Assessment
for Special Cases
• When client’s awareness can’t be
assessed because of unconscious,
awakening is assessed
– Glasgow Coma Scale—assess LOC using 15-point
scale
– Assess for best response to eye opening, motor
response, and verbal response
– Pain—1 descriptor used in assessment of best
eye/motor response

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 Glasgow Coma Scale

• Scale measuring responses. Total

range is from 3 to 15. The higher
the score the better the response.
• Decorticate posturing- rigid flexion
• Decerebrate posturing- rigid
extension– hands and forearms
pronate (turn out).

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Glasgow Coma Scale

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 Age-Related Variations:
Infants/Children: Examination/Findings
• Infants/Children- Ask parents for information about
birth, cry, seizures
– Birth trauma may lead to cerebral palsy
– Shrill cry and sunset eyes may indicate
hydrocephalus
– Seizures may indicate high fever or a neurological
disorder
– ADHD
– Neurologic Soft signs– pg 638

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 Sunset Eyes

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 Age-Related Variations:
Older Adults: Examination
Normal and abnormal findings
• Indicators of ability to perform activities of daily living—
personal hygiene, appearance, and dress
• Some older adults have slowed responses, move more
slowly, or show decline in function (e.g., sense of taste)
• Other aging changes—deviation of gait from midline;
difficulty with rapidly alternating movements; some loss
of reflexes and sensations (e.g., knee/ankle jerk reflexes,
light touch/pain sensations)

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 Common Problems and Conditions
Disorders of the CNS
• Alzheimer’s disease-incurable degenerative
• Seizures- postictial is due to low glucose levels
• Meningitis- bacterial worst
• Encephalitis- inflammation of the brain
• Multiple sclerosis- demyelinization of nerve
fibers
• Spinal Cord Injuries
• Parkinson’s- degeneration of dopamine
producing neurons
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 Common Problems and Conditions
Disorders of the CNS
• CVA
• Myasthena Gravis- abnormal weakness of
voluntary muscles
• Guillain-Barre’- widespread demyelinization of
the nerves, progressive
• Hydrocephalus-CSF buildup
• Bell’s palsy
• Cerebral palsy
• ADHD
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