Transcript Neurological Assessmentx

Neurological
Assessment
NURSING 101
The brain, brain stem, and spinal cord
Neuro system function
Brain
◦ Information processing, judgement, speech, positioning, memory, interpreting sensory data
Brain Stem
◦ Reflexes for respiration, BP, HR, cough, vomiting, swallowing, sneezing
Spinal Cord
◦ Conduct sensory and motor impulses to and from brain
◦ Voluntary muscle activity
Brain Lobes
Peripheral Nervous System
Cranial Nerves
Spinal Nerves
Visceral Nerves
Autonomic Nervous System
Part of PNS, controlled by CNS
Sympathetic
Parasympathetic
I (olfactory)
Sensory
Sense of smell
II (optic)
Sensory
Visual acuity and visual fields
III (oculomotor)
Motor
Muscles that move the eye and lid, pupillary constriction, lens
accommodation
IV (trochlear)
Motor
Muscles that move the eye
V (trigeminal)
Mixed
Facial sensation, corneal reflex, mastication
VI (abducens)
Motor
Muscles that move the eye
VII (facial)
Mixed
Symmetry of facial expression and muscle movement in upper
and lower face, salivation and tearing, taste, sensation in the
ear
VIII (acoustic)
Sensory
Hearing and equilibrium
IX (glossopharyngeal)
Mixed
Taste, sensation in pharynx and tongue, pharyngeal muscles,
swallowing
X (vagus)
Mixed
Muscles of pharynx, larynx, and soft palate; sensation in
external ear, pharynx, larynx, thoracic and abdominal viscera;
parasympathetic innervation of thoracic and abdominal organs
XI (spinal accessory)
Motor
Sternocleidomastoid and trapezius muscles
XII (hypoglossal)
Motor
Movement of the tongue
I Olfactory
On
II Optic
Old
III Oculomotor
Olympus’s
IV Trochlear
Towering
V Trigeminal
Top
VI Abducens
A
VII Facial
Finn
VIII Acoustic
And
IX Glossopharyngeal
German
X Vagus
Viewed
XI Spinal Accessory
Some
XII Hypoglossal
Hops
Neurological Assessment
Overall appearance
◦ Posture, movement, affect, level of consciousness
Signs of pain
Seizures
Dizziness/vertigo
Visual disturbances
Muscle weakness
Abnormal sensation
Health History
Muscular dystrophy
Parkinson’s
Epilepsy
Tourettes
Family and personal history
Assessing mental status
“A
& O x 3”
◦ Alert and oriented to person, place, and time (sometimes x 4: add
situation)
Assessing Intellectual Function
Serial 7’s
Proverbs
Analagies
Thought content
Emotional status
Language
Level of Consciousness
Glasgow Coma Scale
PERRLA
Motor Ability
Gait
Spasticity
Rigidity
Flaccidity
Muscle strength
Look for symmetry
Grips/pushes equal
Observe for drift or pronation
Balance and Coordination
Ataxia
Tremors
Romberg Test
Tactile Sensation
Cotton wisp or light fingertip on bilateral parts of body
Compare R-L
Compare proximal to distal
Compare sharp/dull
Neuro assessment
Proprioception
Agnosia
Reflexes
Compare right to left
Wide variation in “normal”
Measured 0-4 +; 2+ usually considered “normal”
Babinski reflex is pathological in adults
Diagnostic Tests of the Nervous System
CT scan
◦ Description:
◦ Nursing implications:
MRI
◦ Description:
◦ Nursing implications
EEG
◦ Description:
◦ Nursing Implications
Lumbar Puncture
◦ Description:
◦ Nursing Implications: