2. Elsevier items and derived items © 2008, 2004, 2000, 1996, 1992 by Saunders, an imprint of Elsevier Inc. Chapter 3: Cultural Competence: Cultural Care Slide 3-1 J Carley MSN, MA, RN, CNE Fall, 2009 The Spinning Woman Illusion --Nobuyuki Kayahara JARVIS, C. (2008) Physical Examination & Health Assessment Chapter 23

3. Unit Objectives Slide 23-2 1. Describe the anatomic structures of the central nervous system and brain. 2. Identify the 12 cranial nerves and their function 3. Complete the Glasgow Coma scale, the Rancho Los Amigos scale, and the mini mental state exam as appropriate for case studies. 4.Explain how to prepare the client for a neurological examination 5. Discuss the appropriate equipment necessary for examining the neurological system.

4. Slide 23-3

5. Slide 23-4

6. Peripheral nerves Peripheral nerves go from spinal cord to arms, hands, legs, and feet Slide 23-5

7. Autonomic nerves Autonomic nerves go to the stomach, intestines, and other parts of the digestive system Slide 23-6

8. Cranial nerves Cranial nerves go from brain to eyes, mouth, ears, and other parts of head (and others…e.g., Vagus) Slide 23-7

9. Slide 23-8

10. Slide 23-9

11. Central Nervous System (CNS)  Cerebral cortex - Frontal lobe - Parietal lobe - Occipital lobe - Wernicke’s area - Broca’s area  Basal ganglia  Thalamus  Hypothalamus  Cerebellum  Brainstem - Midbrain - Pons - Medulla  Spinal cord Slide 23- 10

12. Cerebral Cortex Slide 23- 11

13. Slide 23- 12

14. Slide 23- 13

15. CNS [PRODUCTION NOTE: Please insert Figure 23-2 (from Jarvis Physical Examination and Health Assessment, 5e, ISBN: 978-1-4160-3243-4)] © Pat Thomas, 2006. Slide 23- 14

16. Cranial Nerves I Olfactory II Optic III Oculomotor IV Trochlear, VI Abducens V Trigeminal VII Facial VIII Acoustic (vestibulocochlear) IX Glossopharyngeal X Vagus XI Spinal accessory XII Hypoglossal Slide 23- 15

17. Olfactory I Optic II Oculomotor III Trochlear IV Trigeminal V Abducens VI Facial VII Auditory (vestibulocochlear) VIII Glossopharyngeal IX Vagus X Spinal Accessory XI Hypoglossal XIIOlfactory IOptic IIOculomotor IIITrochlear IVTrigeminal VAbducens VIFacial VIIAuditory (vestibulocochlear) VIIIGlossopharyngeal IXVagus XSpinal Accessory XIHypoglossal XII Cranial Nerves - Introduction Interactive quiz to identify the cranial nerve function. Slide 23- 16

18. CNS Pathways  Sensory pathways - Spinothalamic tract - Posterior (dorsal) column  Motor pathways - Corticospinal or pyramidal tract - Extrapyramidal tracts - Cerebellar system  Upper motor neurons  Lower motor neurons Slide 23- 17

19. Sensory Pathways © Pat Thomas, 2006. Slide 23- 18

20. Motor Pathways © Pat Thomas, 2006. Slide 23- 19

21. Reflex Arc Slide 23- 20

22. Subjective Data  Headache  Head injury  Dizziness or Vertigo  Seizures  Tremors  Weakness Slide 23- 21

23. Subjective Data  In-coordination / “uncoordinated”  Numbness or tingling  Difficulty swallowing  Difficulty speaking (Dysphasia)  Environmental/occupational hazards Slide 23- 22

24. Objective Data  Equipment needed - Penlight - Tongue blade - Toothpick - Cotton swab / Cotton ball - Tuning fork (128 or 256 Hz) - Percussion hammer - Familiar aromatic substance Slide 23- 23

25. Motor System  Muscles - Size - Strength - Tone - Involuntary movements  Cerebellar function - Balance tests - Coordination - Skilled movements Slide 23- 24

26. Romberg Test Negative - ve Normal Positive + veAbnormal Proprioceptive pathway Slide 23- 25

27. Ambulation Slide 23- 26

28. Describe… Slide 23- 27

29. Abnormal Ambulation Asymmetrical Spastic Diplegia Slide 23- 28

30. Neuro Check Neuro Check (Crani Check)  LOC  Level Of Consciousness (LOC) Person Place Time  Motor function  Pupillary response  Vital signs  Glasgow Coma Scale (GCS) Oriented x 3 Slide 23- 29

31. IntraCranial Pressure ICP IntraCranial Pressure = ICP Slide 23- 30 Pressure within the cranial cavity influenced by brain mass, the circulatory system, CSF dynamics, and skull rigidity

32. ICP (IICP) Increased ICP (IICP) Critical event / Life threatening Slide 23- 31

33. Slide 23- 32 intracranial pressure CT scan showing intracranial hemorrhage with cerebral edema, midline shift, and increased intracranial pressure

34. Glasgow Coma Scale Slide 23- 33

35. 34 GCS The GCS is the most widely used method of defining a patient's level of consciousness (LOC)

36. 35

37. 36 Expanded Neuro Assessment Tool

38. Mini-Mental Status Exam Rancho Los Amigos Scale Slide 23- 37

39. EARLY Signs of ↑ ICP EARLY Signs of ↑ ICP 38 ******MOST IMPORTANT**** 1.LOC changes ******MOST IMPORTANT**** 2.Pupils sluggish / Impaired eye movement 3.Limb strength changes 4.Headache The most important neurologic “vital sign” !!!!!!!!!!!!!!!!!!!!!!!!!

40. LATE Signs of ICP LATE Signs of ICP 39 1.Further decreased LOC 2.Cushing’s Triad 3.Abnormal respiration patterns 4.Pupils asymmetrical / Dilated 5.Projectile vomiting 6.Hemiplegia / decorticate or decerebrate posturing anisicoria “fixed & dilated “Call the neurosurgeon” “Call the chaplain.” Pupils..

41. Cushing’s “Triad” Blood Pressure (Widening Pulse Pressure) Temperature Pulse 40 Late Sign of IICP

42. Abnormal Postures  Flaccid quadriplegia  Decorticate rigidity  Decerebrate rigidity Slide 23- 41

43. Slide 23- 42 “Toward the Core”

44. 43

45. Dilated ? Consenusal ? Shape ? Pupil Responses Slide 23- 44

46. Rapidly Alternating Movement (RAM) Evaluation Slide 23- 45

47. Finger to Nose Test Slide 23- 46

48. Heel to Shin Coordination Test Slide 23- 47

49. Test Deep Tendon Reflexes Technique Grading Babinski’s sign Biceps reflex Triceps reflex Brachioradialis reflex Quadriceps reflex Achilles reflex (“ankle jerk”) Abdominal reflexes Slide 23- 48

50. Reflexes Slide 23- 49

51. Babinski Reflex A normal response, B Babinski reflex Positive + ve Abnormal N Negative - ve N Normal Slide 23- 50

52. INTACTNESS REFLEX ARC Testing the DTR’s provides data about the INTACTNESS of the REFLEX ARC at specific levels in the spinal cord. Slide 23- 51

53. Abnormalities in Muscle Movement  Paralysis  Fasciculations  Flaccidity  Ataxia  Rest tremor  Intention tremor  Paresthesia  Coma Slide 23- 52

54. Sensory System  Spinothalamic tract - Pain - Temperature - Light touch  Posterior column tract - Vibration - Position (kinesthesia) - Tactile discrimination (stereognosis, graphesthesia)  Alert, cooperative, and comfortable Slide 23- 53

55. Aged Aged – “ Less ” is Normal - Walk slower - More careful walking - Decreased tactile sensation - Lose ability to feel vibration at ankles - Decreased ability to smell Slide 23- 54

56. Cultural Considerations “ Cultural Considerations “Epilepsy” Uganda Uganda: contagious, untreatable Greece Greece: source of family shame Mexican-American Mexican-American: evidence of physical imbalance Hutterites: Hutterites: having endured a trial by God Slide 23- 55

57. Narrative Charting Slide 23- 56 Denies any of the following: frequent or severe headaches; history of head injury, dizziness, or vertigo. Denies weakness, numbness, or tingling; no difficulty swallowing or speaking. No past history of stroke, meningitis, spinal cord injury, or alcoholism.

58. Slide 23- 57 Narrative Charting

59. Slide 23- 58

60. Slide 23- 59 Jarvis Page 679

61. Neuro Assessments Neuro Assessment Practice: http://icarus.med.utoronto.ca/NeuroExam/ Slide 23- 60

62. Which area of the brain is most likely affected if the patient is having trouble with the finger-to-nose test? A.Cerebellum B.Cerebrum C.Hypothalmus D.Brain stem Slide 23- 61

63. Vibratory sense is most frequently affected in cases of? A.Heart disease B.Crohns’ disease C.Lung Cancer D.Diabetes Slide 23- 62

64. Brain Teasers Slide 23- 63 http://brainconnection.positscience.com/teasers/

65. The Hermann Grid Illusion This phenomena demonstrates a very important principle of perception: we don't always see what's really there. Our perceptions depend upon how our visual system responds to environmental stimuli and how our brain then interprets this information. 1 Slide 23- 64 1 Bach, M. (n.d.). Grid illusions. http://www.michaelbach.de/ot/lum_herGrid/index.html

66. The Zollner Illusion This illusion presents a series of oblique lines crossed with overlapping short lines. The oblique lines look as if they are crooked and will diverge. In reality, all of the oblique lines are parallel.This optical illusion demonstrates how the background of an image can distort the appearance of straight lines. Slide 23- 65

67. Slide 23- 66 The End