NURS2520 Health Assessment II Neurological Assessment

Objective One Assess the components of the basic neurological assessment

The brain is highly dependent on blood flow and a consistent supply of oxygen and glucose to maintain neuronal function. Any decrease can cause neuronal malfunction. Older adults tend to be vulnerable to cognitive dysfunction secondary to many causes, ranging from decreased blood pressure to infections. Thus, any acute change in cognitive functioning needs to be assessed for an underlying cause.

Neurological System Functions through transmission of chemical and electrical signals between the body and the brain Receives, processes, and sends out information Controls and coordinates the functioning of all other systems in response to environment/surroundings Involves cognition, emotion, memory, sensation and perception, and regulation of homeostasis Comprised of the central nervous system (CNS) and the peripheral nervous system (PNS) CNS = Brain and spinal cord PNS = Cranial and spinal nerves

Two neurons with synapse (from MyNursingLab)

The PNS includes nerves emerging from the brain (cranial nerves) and nerves emerging from the spinal cord (spinal nerves). These nerves are divided into sensory nerves that conduct messages from various parts of the body to the CNS, whilst motor nerves conduct impulses from the CNS to muscles and glands. is further divided into the Somatic System (SNS) and Autonomic System (ANS), depending on the area of the body these messages are transmitted to and from.

The SNS consists of sensory neurons from the head, body wall, extremities, and motor neurons to skeletal muscle. The motor responses are under conscious control and therefore the SNS is voluntary. Certain peripheral nerves perform specialized functions and form the autonomic nervous system; they control various activities that occur automatically or involuntarily such as the contraction of smooth muscle in the walls of the digestive system. The autonomic system is further divided into the sympathetic and parasympathetic systems. These two systems provide nerve stimuli to the same organs throughout the body, but bring about different effects. The balance between these two systems is controlled to create a state of homeostasis that is where the internal stability of the bodily systems are maintained in response to the external environment

Parasympathetic Nervous System slows down the body helps prepare for a more relaxed state, ready for digestion and sleep. It will therefore increase peristalsis of the alimentary canal, slow down the heart rate, and constrict the bronchioles in the lungs. .

The Sympathetic Nervous System helps prepare the body for "fight or flight" and create conditions in the tissues for physical activity. is stimulated by strong emotions such as anger and excitement and will therefore speed up heart rate, increase the activity of sweat glands, adrenal glands, and decrease those of the digestive system. also produces rapid redistribution of blood between the skin and skeletal muscles.

Brain and spinal cord (from MyNursingLab)

Age-Related Considerations Birth reflexes include rooting, sucking, palmar grasp, tonic neck reflex, and Moro Disappear during infancy May return w/stroke or trauma Denver Developmental Screening Test II (DDST) used to screen young children Neurons decrease over lifetime, resulting in slowed reaction time, problem-solving skills, and voluntary movement Decreases in intelligence and memory not normal in the elderly, and indicate a neurological deficit Medication effects, dehydration, Alzheimer’s dementia, etc

Cerebral Function Level of consciousness (LOC) Arousal (alert, lethargic, stuporous, comatose) Verbal stimuli Tactile stimuli Painful stimuli Orientation (person, place, time) Mental status and cognitive function Behavior, appearance, response to external stimuli, speech, recent and remote memory, communication, judgment Posture, gait, motor movements, dress, hygiene/grooming, mood, affect, facial expression Consider language/education/culture during neuro exam

Glasgow Coma Scale

Objective Two Demonstrate the proper technique for the assessment of reflex activity

Reflex Function Deep tendon reflex is tested with a rubber percussion hammer to tap a slightly stretched muscle Normal response = muscle contraction Response grading scale: 0 = No response detected +1 = Diminished response +2 = Response normal +3 = Response somewhat stronger than normal +4 = Response hyperactive with clonus Clonus refers to involuntary continuous contractions of a muscle or group of muscles Superficial reflexes are tested by lightly touching the body with the base of a reflex hammer or tongue blade, beginning with the most peripheral part of the limb Graded as positive or negative Determine sensory loss area by testing every 1-2 inches

Testing Reflexes Biceps Reflex Triceps Brachioradialis Patellar Rest client’s elbow in nondominant hand with thumb over biceps tendon; strike percussion hammer to own thumb Triceps Abduct client’s arm at the shoulder, flexing at the elbow; support upper arm with nondominant hand, letting forearm hang loosely; strike the triceps tendon 2 inches above the olecranon process Brachioradialis Rest client’s arm on his leg; strike with percussion hammer 1-2 inches above bony prominence of the wrist on the thumb side Patellar Position client in seated position with legs dangling; strike the tendon directly below the patella with a percussion hammer Achilles Position client in the supine or seated position with legs dangling; hold client’s foot slightly dorsiflexed; strike the Achilles tendon about 2 inches above the heel with the percussion hammer Plantar Superficial Stroke the sole of the client’s foot in an arc from the lateral heel to medially across the ball of the foot http://www.youtube.com/watch?v=kOq5Np0eZ6A&feature=related Deep Tendon Reflexes: http://www.youtube.com/watch?v=fymDY2q0FtE&feature=related

Objective Three Demonstrate the assessment techniques employed in the assessment of cranial nerves

Dorsal aspect of brain w/cranial nerves (from MyNursingLab)

Cranial Nerves

Checking Cranial Nerves CN I Identify the smell of common substances CN II Test visual acuity and visual fields CN III, IV, & VI Test extraocular movement by having client move eyes through the 6 cardinal fields of gaze with head held steady; test papillary reaction to light and accommodation http://www.youtube.com/watch?v=YntJiBCz3pA&feature=related CN V - Motor function Move jaw from side to side, clenching jaw, and biting down on a tongue blade CN V - Sensory function Have client close eyes and identify when he is being touched on the forehead, cheeks, and chin; test corneal reflex by puffing air over the cornea CN VII - Motor function Have client make faces (smile, frown, whistle) CN VII - Taste Test taste on anterior portion of tongue by placing something sweet, salty, or sour on the tip of the client’s tongue CN VIII Test client’s hearing using wristwatch; test air/bone conduction using Weber & Rinne test; test for balance using Romberg test http://video.google.com/videoplay?docid=1911735836954444981# http://www.youtube.com/watch?v=4hOSkmDYAR4&NR=1

Checking Cranial Nerves CN IX & X - Motor function Observe client’s ability to talk, swallow, and cough; have client say “ahhh” while depressing tongue with tongue blade and observing rise of soft palate and uvula CN IX & X - Sensory function Induce client’s gag reflex (do NOT perform in lab practice) CN IX & X - Taste Test taste on posterior portion of tongue by placing something sweet, salty, or sour at the back of the client’s tongue CN XI Place hands on client’s shoulders, and have him shrug shoulders against resistance; have client turn head from side to side against resistance CN XII Have client say “d”, “l”, “n”, “t”; have client protrude tongue and move it from side to side

Neuro exam Part 1 http://www.youtube.com/watch?v=nABAdENIbXY&feature=related Part 2 http://www.youtube.com/watch?v=_1Rd1wVeqU4&feature=related

Objective Four Demonstrate the complete assessment of the neurological system (*Lab Practice)